Causes and consequences of child growth faltering in low-resource settings.

Growth faltering in children (low length for age or low weight for length) during the first 1,000 days of life (from conception to 2 years of age) influences short-term and long-term health and survival1,2. Interventions such as nutritional supplementation during pregnancy and the postnatal period could help prevent growth faltering, but programmatic action has been insufficient to eliminate the high burden of stunting and wasting in low- and middle-income countries. Identification of age windows and population subgroups on which to focus will benefit future preventive efforts. Here we use a population intervention effects analysis of 33 longitudinal cohorts (83,671 children, 662,763 measurements) and 30 separate exposures to show that improving maternal anthropometry and child condition at birth accounted for population increases in length-for-age z-scores of up to 0.40 and weight-for-length z-scores of up to 0.15 by 24 months of age. Boys had consistently higher risk of all forms of growth faltering than girls. Early postnatal growth faltering predisposed children to subsequent and persistent growth faltering. Children with multiple growth deficits exhibited higher mortality rates from birth to 2 years of age than children without growth deficits (hazard ratios 1.9 to 8.7). The importance of prenatal causes and severe consequences for children who experienced early growth faltering support a focus on pre-conception and pregnancy as a key opportunity for new preventive interventions.

Astragalus polysaccharide prevents heart failure-induced cachexia by alleviating excessive adipose expenditure in white and brown adipose tissue.

BACKGROUND: Astragalus polysaccharide (APS) is a key active ingredient isolated from Astragalus membranaceus that has been reported to be a potential treatment for obesity and diabetes by regulating lipid metabolism and adipogenesis, alleviating inflammation, and improving insulin resistance. However, whether APS regulates lipid metabolism in the context of cachexia remains unclear. Therefore, this study analysed the effects of APS on lipid metabolism and adipose expenditure in a heart failure (HF)-induced cardiac cachexia rat model.  METHODS: A salt-sensitive hypertension-induced cardiac cachexia rat model was used in the present study. Cardiac function was detected by echocardiography. The histological features and fat droplets in fat tissue and liver were observed by H&E staining and Oil O Red staining. Immunohistochemical staining, Western blotting and RT‒qPCR were used to detect markers of lipolysis and adipose browning in white adipose tissue (WAT) and thermogenesis in brown adipose tissue (BAT). Additionally, sympathetic nerve activity and inflammation in adipose tissue were detected. RESULTS: Rats with HF exhibited decreased cardiac function and reduced adipose accumulation as well as adipocyte atrophy. In contrast, administration of APS not only improved cardiac function and increased adipose weight but also prevented adipose atrophy and FFA efflux in HF-induced cachexia. Moreover, APS inhibited HF-induced lipolysis and browning of white adipocytes since the expression levels of lipid droplet enzymes, including HSL and perilipin, and beige adipocyte markers, including UCP-1, Cd137 and Zic-1, were suppressed after administration of APS. In BAT, treatment with APS inhibited PKA-p38 MAPK signalling, and these effects were accompanied by decreased thermogenesis reflected by decreased expression of UCP-1, PPAR-γ and PGC-1α and reduced FFA ß-oxidation in mitochondria reflected by decreased Cd36, Fatp-1 and Cpt1. Moreover, sympathetic nerve activity and interleukin-6 levels were abnormally elevated in HF rats, and astragalus polysaccharide could inhibit their activity. CONCLUSION: APS prevented lipolysis and adipose browning in WAT and decreased BAT thermogenesis. These effects may be related to suppressed sympathetic activity and inflammation. This study provides a potential approach to treat HF-induced cardiac cachexia.

Quality assessment of cancer cachexia clinical practice guidelines.

OBJECTIVES: The aim of this study was to investigate the quality of clinical practice guidelines of cancer cachexia and identify gaps limiting knowledge. METHODS: A systematic search of relevant guideline websites and literature databases (including PubMed, NCCN, NGC, SIGN, NICE, and google) was undertaken from inception to March 2017 to identify and select clinical guidelines related to cancer cachexia. Four independent reviewers assessed the eligible guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Agreement among reviewers of the guidelines was measured by using intra-class correlation coefficient (ICC). The number of recommendations, strength of recommendation, and levels of evidence were determined. RESULTS: Nine cancer cachexia guidelines published from 2006 to 2017 were identified. An overall high degree of agreement among reviewers to each domain was observed (ICC ranged from 0.75 to 0.91). The median scores and range for each AGREE II domain were as follows: (i) scope and purpose (median = 61.1%, range: 13.9% to 80.7%); (ii) stakeholder involvement (median = 26.4%, range: 8.3% to 81.9%); (iii) rigour of development (median = 35.9%, range: 3.6% to 84.4%); (iv) clarity and presentation (median = 56.9%, range: 30.6% to 76.4%); (v) applicability (median = 19.8%, range: 0% to 77.1%) and (vi) editorial independence (median = 27.1%, range: 0% to 85.4%). Two cancer cachexia guidelines (ESPEN, 2017 and University of Queensland, 2013) scored higher on all domains and were classified as recommended for clinical practice, among which, one was developed by European Society for Parenteral and Enteral Nutrition and European Partnership for Action Against Cancer, and the other was developed by University of Queensland. In addition, more than a half recommendations were based on nonrandomized studies (Level C, 50.0%) and expert opinion (Level D, 8.2%). CONCLUSIONS: The quality of cancer cachexia guidelines was highly heterogeneous among different domains even within the same guideline. There is significant room for improvement to develop high quality cancer cachexia guidelines, which urgently warrants first-class research to minimize the vital gaps in the evidence for formulation of cancer cachexia guidelines.

The final word on nutritional screening and assessment in older persons.

PURPOSE OF REVIEW: To provide an updated perspective of how nutritional screening and assessment in older persons should be performed and reasonably implemented in the near future. RECENT FINDINGS: Although nutritional screening and assessment should be fast and easy procedures, there is increasing evidence that more time should be dedicated to them. This is probably an answer to the claim to a medicine being more preventive than curative. Increasing interest is currently given to healthy aging and nutritional status is more likely to be addressed for its implications on functional status and disability. Important prognostic conditions, such as frailty, sarcopenia, and cachexia, which are closely linked to the nutritional domain, are at the top of the agenda. Therefore, body composition is a key issue and functional status is suggested as primary endpoint of nutrition trials. In this scenario, there is also a rationale for systematic assessment of inflammation, protein intake, and vitamin D status as potential contributing factors to reduced muscle mass and function. SUMMARY: A 'second-generation' multidimensional nutritional screening and assessment including the evaluation of body composition, frailty, sarcopenia, and cachexia could be hypothesized. Nutritional assessment should be also completed by the systematic evaluation of inflammation, protein intake, and vitamin D status.

[FACTORS WHICH INFLUENCE THE LEAN MASS LOSS IN CANCER PATIENTS]. / FACTORES QUE INFLUYEN EN LA PÉRDIDA DE MASA MAGRA EN PACIENTES ONCOLÓGICOS.

INTRODUCTION: cancer is an important illness in the sanitary field due to phisic and functional consequences involved in it. Among these consequences there is the malnutrition which can cause a loss of lean mass and with it a decrease in the Quality of Life, an increase in hospital stays, social and health costs and so on. The aim of this research is to know which factors can influence in the loss of the lean mass. MATERIAL AND METHODS: it is a cross-sectional study in a sample of 72 patients who receive a radiotherapy with curative intent during a period from February 07th and May 14th, 2014. RESULTS: from this pattern Of the total 64 patients were studied, of which 43.7% of the patients presented loss of lean mass, with 21.8% the percentage of patients losing < 2%, 4.7% those with a loss between 2-5% and > 5%, 17.2% of patients. Among the factors studied that can influence the loss of lean mass, only the presence of digestive symptoms have statistical significance (OR = 3.3 or 6.6, as we take as a reference the percentage loss). CONCLUSIONS: the aim of the health staff who are working with these patients is to avoid the consequences that accompanies the loss of lean mass. For all this, it is very important to act before the digestive symptoms, by anticipating to them, or early implementation of an individualized nutritional intervention.

Introducción: el cáncer es una enfermedad de gran importancia sanitaria debido a las consecuencias físicas y funcionales que conlleva. Entre estas consecuencias está la desnutrición, que puede provocar una pérdida de masa magra y con ello una disminución de la calidad de vida, aumento de las estancias hospitalarias, costes sanitarios, etc. El objetivo de este estudio es conocer qué factores influyen en la pérdida de masa magra. Material y métodos: se trata de un estudio transversal en una muestra de 72 pacientes que reciben tratamiento radioterápico con finalidad curativa en un período comprendido entre el 7 de febrero y el 14 de mayo de 2014. Resultados: del total de pacientes se estudiaron 64, de los cuales el 43,7% presentan pérdida de masa magra, siendo el porcentaje de 21,8% los pacientes que pierden < 2%, el 4,7% los que presentan una pérdida entre el 2-5% y > 5%, el 17,2% de los pacientes. De entre los factores estudiados que pueden influir en la pérdida de masa magra, solo la presencia de síntomas digestivos poseen significación estadísitca (OR = 3,3 o 6,6, según tomemos como referencia el porcentaje de pérdida). Conclusiones: el objetivo del personal sanitario que trabaja con estos pacientes de evitar las consecuencias que acompañan a la pérdida de masa magra. Por todo esto, es importante actuar antes de la aparición de síntomas digestivos, mediante la prevención de los mismos, o la aplicación precoz de una intervención nutricional individualizada.

The economic costs of disease related malnutrition.

BACKGROUND & AIMS: Disease related malnutrition (under-nutrition caused by illness) is a worldwide problem in all health care settings with potentially serious consequences on a physical as well as a psycho-social level. In the European Union countries about 20 million patients are affected by disease related malnutrition, costing EU governments up to € 120 billion annually. The aim of this study is to calculate the total additional costs of disease related malnutrition in The Netherlands. METHODS: A cost-of-illness analysis was used to calculate the additional total costs of disease related malnutrition in adults (>18 years of age) for The Netherlands in 2011 in the hospital, nursing- and residential home and home care setting, expressed as an absolute monetary value as well as a percentage of the total Dutch national health expenditure and as a percentage of the total costs of the studied health care sectors in The Netherlands. RESULTS: The total additional costs of managing adult patients with disease related malnutrition were estimated to be € 1.9 billion in 2011 which equals 2.1% of the total Dutch national health expenditure and 4.9% of the total costs of the health care sectors analyzed in this study. CONCLUSIONS: The results of this study show that the additional costs of disease related malnutrition in adults in The Netherlands are considerable.

Validation of the Head and Neck Patient Symptom Checklist as a nutrition impact symptom assessment tool for head and neck cancer patients.

PURPOSE: The purpose of this study was to test the validity of the Head and Neck Patient Symptom Checklist (HNSC). METHODS: Three hundred and sixty-eight treatment-naive individuals with head and neck cancer prospectively completed the HNSC and the Patient-Generated Symptom Global Assessment (PG-SGA). The predictive validity was determined by comparing the HNSC symptoms interference scores to the PG-SGA scores. Multivariate logistic regression was used to determine the HNSC symptoms scores associated with reduced dietary intake, ≥ 5 % weight loss over 6 months, and reduced functional performance (FP). RESULTS: HNSC sensitivity (79-98 %), specificity (99-100 %), positive predictive value (92-100 %), and negative predictive value (94-100 %) were excellent, and the Cronbach's alpha coefficient was 0.92. The multivariate logistic regression showed that advanced tumor stage, pain, loss of appetite (LOA), and difficulty swallowing significantly predicted dietary intake. Advanced tumor stage, LOA, and difficulty swallowing were also significant predictors of ≥ 5 % weight loss over 6 months. LOA, difficulty swallowing, feeling full, and lack of energy were significant predictors of reduced FP. CONCLUSIONS: The HNSC appears to be a valid tool for determining symptoms interfering with dietary intake of head and neck cancer (HNC) patients. This instrument may aid in early identification of symptoms that place HNC patients at risk for reductions in dietary intake, weight, and functional performance.

Nutrition assessment and management in children on peritoneal dialysis.

Protein-calorie malnutrition, otherwise known as cachexia, is a common problem in children undergoing chronic peritoneal dialysis (PD) and is a frequent source of significant morbidity and mortality. Recent evidence suggests that the main factors involved in the pathogenesis are metabolic acidosis, a decreased response to anabolic hormones, and chronic inflammation, associated with hormonal imbalances and an increased metabolic rate. Given the complexity and multifactorial nature of cachexia, the assessment of nutritional status in children on PD requires a complete history and physical examination; assessment of dietary intake, biochemical indices, and anthropometry; and possibly bioimpedance analysis and combined score systems. Its management should likewise be multidisciplinary and include ensuring an adequate energy and protein intake; optimal metabolic control, with the correction of acidosis, anaemia, and hyperparathyroidism; an optimal (or at least adequate) dialysis dose; and, if necessary, prescription of specific drugs such as recombinant human growth hormone.

Assessment and monitoring of nutritional status in patients with advanced cancer: part 1.

Using a qualitative approach, this study set out to explore nurses' management of patients with advanced cancer, weight loss and eating-associated problems. Extreme weight loss is commonly seen in patients with incurable solid tumour cancer and, to date, it has proved difficult to manage successfully. Currently, little is known about how nurses (often directly involved in the delivery of palliative care) assess weight loss and nutritional status in everyday practice in order to provide appropriate support. In this study, 14 semi-structured interviews were conducted with nurses from both hospital and community settings. The findings revealed that many nurses did not routinely provide early identification and assessment of nutritional status including weight loss, nor did they continue to monitor the patient's progress or deterioration. Many nurses were reluctant to initiate conversations with cancer patients about weight loss, but instead waited for patients and relatives to raise their concerns. As a result, it is likely that informal assessment may have resulted in the reactive style of nutritional management seen. However, nurses interviewed received limited training, but were keen to learn more about nutritional assessment and management.

Toward a core nutraceutical program for cancer management.

As previously suggested, it may be feasible to impede tumorevoked angiogenesis with a nutraceutical program composed of glycine, fish oil, epigallocatechin-3-gallate, selenium, and silymarin, complemented by a low-fat vegan diet, exercise training, and, if feasible, a salicylate and the drug tetrathiomolybdate. It is now proposed that the scope of this program be expanded to address additional common needs of cancer patients: blocking the process of metastasis; boosting the cytotoxic capacity of innate immune defenses (natural killer [NK] cells); preventing cachexia, thromboembolism, and tumor-induced osteolysis; and maintaining optimal micronutrient status. Modified citrus pectin, a galectin-3 antagonist, has impressive antimetastatic potential. Mushroombeta-glucans and probiotic lactobacilli can amplify NK activity via stimulatory effects on macrophages. Selenium, beta-carotene, and glutamine can also increase the number and/or cytotoxic activity of NK cells. Cachectic loss of muscle mass can be opposed by fish oil, glutamine, and beta-hydroxy-beta-methylbutyrate. Fish oil, policosanol, and vitamin D may have potential for control of osteolysis. High-dose aspirin or salicylates, by preventing NF-B activation, can be expected to aid prevention of metastasis and cachexia while down-regulating osteolysis, but their impacts on innate immune defenses will not be entirely favorable. A nutritional insurance formula crafted for the special needs of cancer patients can be included in this regimen. To minimize patient inconvenience, this complex core nutraceutical program could be configured as an oil product, a powder, and a capsule product, with the nutritional insurance formula provided in tablets. It would be of interest to test this program in nude mouse xenograft models.

Modern palliative care: an exercise in prevention and partnership.

Palliative care is no longer solely an excercise in controlling suffering at the end of life. If we are to apply the principles of palliative care throughout the course of illness, both the culture and the organization of palliative care services must change. New partners must be enlisted in more sophisticated, increasingly academic partnerships. This change, while welcome and necessary, must come about with perservation of the core values of palliative care.

[Prevention of wasting and opportunistic infections in HIV-infected patients in West Africa: a realistic and necessary strategy before antiretroviral treatment]. / Prévention de la dénutrition et des infections opportunistes chez lespatients infectés par le VIH en Afrique de l'Ouest: une démarche réaliste, nécessaire, préalabe aux antirétroviraux.

The medical inequalities between countries of the North and South (infrastructure, drug availability, medical techniques) are particularly marked in terms of the challenge posed by HIV infection. We propose a strategy for monitoring adult patients in West Africa that is appropriate to the situation in the field and to economic constraints. The aim of this strategy is to increase the quality of life and the life expectancy of HIV-infected adults and to prevent the overcrowding of hospital departments with patients in the terminal phase of AIDS. We analyzed the biological and clinical spectrum of HIV infection before the onset of the diseases that define AIDS (excluding pulmonary tuberculosis). We found that it was particularly important to diagnose B-stage diseases early, especially atypical chronic cutaneous and mucous diseases. Careful analysis of data from a routine hemogram (total lymphocyte count 2500/ml; paradoxical eosinopenia), even in the absence of a CD4 lymphocyte count, should also enable clinicians from a wide variety of health structures to identify the HIV-infected patients most likely to benefit from more detailed clinical follow up, prophylaxis of opportunistic infections using cotrimoxazole, nutritional checkups and prevention of wasting. Cachexia is the most common AIDS-associated disease in West African patients. It involves an overall decrease in calorific intake, diarrhea, immune system activation, an increase in TNFalpha production and greater energy expenditure when resting. Recent nutritional studies have shown that it is vital to optimize the calorific intake of HIV-infected patients presenting with chronic diarrhea, before the onset of severe immune deficiency, to prevent wasting. So, spontaneous calorific intake should de routinely determined in HIV-infected patients and an optimal diet provided. Specific training in nutrition is required for doctors and nurses, as is consideration of the logistic organization required to provide nutritional support to HIV-infected adults. Despite the large number of individuals infected and the lack of sophisticated paraclinical facilities, we feel that it is possible to establish rational management "a minima" of HIV infection in West Africa, whilst waiting for antiretroviral drugs to become more widely available. This strategy could be of direct benefit to patients without swallowing up the financial resources of the health system in expensive biological follow up. Such basic management is also required before the new antiretroviral drugs become widely available. Research should be carried out in parallel in several reference centers in West Africa to determine the most effective associations of antiretroviral drugs and the optimal timing of treatment during the course of infection and to assess the potential side effects of these drugs in HIV patients exposed to recurrent antigenic stimulation by a wide diversity of pathogens.

Energy expenditure in Alzheimer's disease.

Alzheimer's disease type dementia is a growing health problem and is one of the leading causes of death among elderly people. Unexplained weight loss and cachexia is a frequent clinical finding in patients with Alzheimer's disease. It has been postulated that Alzheimer's disease may by characterized by dysfunction in body weight regulation. This brief review examines energy intake, energy expenditure and body composition in Alzheimer's disease. We consider whether inappropriately high levels of energy expenditure may contribute to unexplained weight loss and decline in nutritional status. Specifically, we will consider studies that have examined body composition, daily energy expenditure and its components. The application of doubly labeled water and indirect calorimetry to problems of "wasting" has increased our knowledge regarding energy expenditure and physical activity levels in Alzheimer's patients. Although the number of studies are limited, results do not support the notion that a "hypermetabolic" state contributes to unexplained weight loss in Alzheimer's disease, even in cachectic patients. Clinical strategies aimed at developing feeding strategies to maintain adequate caloric intake and the restoration of energy balance should be a future area of investigation in Alzheimer's research.

Primary care of the HIV patient: standard practice and new developments in the era of managed care.

It is easy when taking care of the patient with AIDS to lose sight of the whole person and become focused on the details of micromanagement, distracted by the array of new therapies, and overwhelmed by the financial risks of the disease. It is therefore critical that a healing and respectful relationship is developed with patients and they are engaged in the decisions regarding their care. Physicians must also continue the search for new therapies and struggle to ensure that patients have access to state-of-the-art treatment. In this, the primary care physician plays a critical role, through identifying study centers, becoming an investigator in expanded access programs, and using referrals to clinical trials to provide new therapies to patients and improve understanding of HIV treatment. Finally, quality of life must be at the forefront of physicians' medical conscience. Ultimately, the physician must know when the best treatment he of she can offer is the assurance of a dignified and comfortable death.