Animal Models of Undernutrition and Enteropathy as Tools for Assessment of Nutritional Intervention.

: Undernutrition is a major public health problem leading to 1 in 5 of all deaths in children under 5 years. Undernutrition leads to growth stunting and/or wasting and is often associated with environmental enteric dysfunction (EED). EED mechanisms leading to growth failure include intestinal hyperpermeability, villus blunting, malabsorption and gut inflammation. As non-invasive methods for investigating gut function in undernourished children are limited, pre-clinical models are relevant to elucidating the pathophysiological processes involved in undernutrition and EED, and to identifying novel therapeutic strategies. In many published models, undernutrition was induced using protein or micronutrient deficient diets, but these experimental models were not associated with EED. Enteropathy models mainly used gastrointestinal injury triggers. These models are presented in this review. We found only a few studies investigating the combination of undernutrition and enteropathy. This highlights the need for further developments to establish an experimental model reproducing the impact of undernutrition and enteropathy on growth, intestinal hyperpermeability and inflammation, that could be suitable for preclinical evaluation of innovative therapeutic intervention.

Resting Energy Expenditure and Substrate Oxidation in Malnourished Patients With Type 1 Glycogenosis.

CONTEXT: Type 1a and 1b glycogenosis [glycogen storage disorder (GSD)1a, GSD1b] are rare diseases generally associated with malnutrition. Although abnormal substrate oxidation rates and elevated energy expenditures might contribute to malnutrition, this issue has not been investigated. OBJECTIVE: To investigate whether abnormal resting energy expenditure (REE) and substrate oxidation rate characterize patients with GSD1. DESIGN: Cross-sectional study. SETTING: Outpatient referral center for rare diseases and laboratory of clinical nutrition at the University Hospital of Palermo. PATIENTS: Five consecutive patients with GSD1 (4 type a, 1 type b; 3 men, 2 women; age range, 19 to 49 years). MAIN OUTCOME MEASURES: The usual clinical procedures for patients with malnutrition, including REE and basal substrate oxidation rate (both indirect calorimetry), body composition (bioimpedance method), muscle strength (hand-grip test), and the usual laboratory tests, were performed. RESULTS: Malnutrition was clearly diagnosed in 2 patients (1 GSD1a and 1 GSD1b), with REE elevated in all five patients, and especially, in the two malnourished patients (+124% and +32.1% vs predictive values using Harris-Benedict equations). The two malnourished patients also exhibited lower basal protein oxidation rates (7.7% and 6.6%) than the nourished patients (range, 12.1% to 24.7%), with higher carbohydrate or lipid oxidation rates. Additionally, the two malnourished patients exhibited higher blood concentrations of lactic acid than the nourished patients. CONCLUSIONS: According to data obtained from our small sample of patients with GSD1, elevated REEs seem to be a common characteristic that might contribute to malnutrition. Low basal protein oxidation rates and elevated blood lactic acid concentrations appear to be associated with malnutrition.

Anabolic competence: Assessment and integration of the multimodality interventional approach in disease-related malnutrition.

Disease-related malnutrition (DRM) is a frequent clinical problem, characterized by loss of lean body mass and decreased function, including muscle function and immunocompetence. In DRM, nutritional intervention is necessary, but it has not consistently been shown to be sufficient. Other factors, for example, physical activity and hormonal or metabolic influencers of the internal milieu, are also important in the treatment of DRM. A prerequisite for successful treatment of DRM is the positive balance between anabolism and catabolism. The aim of this review was to approach DRM using this paradigm of anabolic competence, for conceptual and practical reasons. Anabolic competence is defined as "that state which optimally supports protein synthesis and lean body mass, global aspects of muscle and organ function, and immune response." Anabolic competence and interdisciplinary, multimodality interventions create a practical foundation to approach DRM in a proactive comprehensive way. Here, we describe the paradigm of anabolic competence, and its operationalization by measuring factors related to anabolic competence and suited for clinical management of patients with DRM.

Performance of alternative measures to body mass index in the assessment of moderate and severe under-nutrition among acutely unwell patients hospitalized in a TB ward in the Philippines: A cross-sectional study.

Body mass index (BMI) kg/m2 is a key screening tool for under-nutrition in adults, but difficult to obtain in immobile or unwell patients, particuarly in low resource settings, due to inability to accurately measure both weight and height. Mid-upper arm circumference (MUAC) is used to assess under-nutrition in children under 5 years but no standardised cut-off values exist for adults. In a cohort of adult Filipino patients admitted to a tuberculosis ward we assessed (i) cut-offs for MUAC to predict moderate under-nutrition (BMI <17kg/m2), (ii) the performance of limb lengths to predict height and; (iii) associations of body fat percentage from skinfolds and hand grip-strength with BMI. In 303 patients with MUAC and BMI at admission, aged 18-80 years (mean = 45.5, SD:14.8), BMI ranged from 11.2-30.6 kg/m2 and 141 (46.5%) had BMI <17.0 kg/m2. Using receiver operator curves, MUAC cut-offs were identified as <20.5cm for males (sensitivity: 89%, specificity: 84%) and <18.5cm for females (sensitivity: 91%, specificity: 89%), for BMI<17.0 kg/m2. Using published equations, knee height had the lowest mean difference between predicted and measured heights compared to ulnar or demi-span: (-0.98 cm, 95% CI: -1.51/-0.44). Both grip-strength and body fat percentage were positively associated with BMI, in separate linear regression models with exposure-age-sex interactions (adjusted-R-squared values: 0.15, 0.66, respectively). MUAC can predict moderate acute under-nutrition with high positive predictive value. Further research is required to determine the performance of alternative measures to BMI to predict mortality or adverse outcomes in acutely unwell patients.

Are Predictive Energy Expenditure Equations Accurate in Cirrhosis?

Malnutrition is associated with significant morbidity and mortality in cirrhosis. An accurate nutrition prescription is an essential component of care, often estimated using time-efficient predictive equations. Our aim was to compare resting energy expenditure (REE) estimated using predictive equations (predicted REE, pREE) versus REE measured using gold-standard, indirect calorimetry (IC) (measured REE, mREE). We included full-text English language studies in adults with cirrhosis comparing pREE versus mREE. The mean differences across studies were pooled with RevMan 5.3 software. A total of 17 studies (1883 patients) were analyzed. The pooled cohort was comprised of 65% men with a mean age of 53 ± 7 years. Only 45% of predictive equations estimated energy requirements to within 90⁻110% of mREE using IC. Eighty-three percent of predictive equations underestimated and 28% overestimated energy needs by ±10%. When pooled, the mean difference between the mREE and pREE was lowest for the Harris⁻Benedict equation, with an underestimation of 54 (95% CI: 30⁻137) kcal/d. The pooled analysis was associated with significant heterogeneity (I2 = 94%). In conclusion, predictive equations calculating REE have limited accuracy in patients with cirrhosis, most commonly underestimating energy requirements and are associated with wide variations in individual comparative data.

Accuracy of Predictive Equations for Energy Expenditure in Mexicans Living With HIV/AIDS With and Without Antiretroviral Therapy.

INTRODUCTION: Determination of the resting energy expenditure (REE) is essential for planning nutrition therapy in patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) to help to improve their nutrition status. We aim to evaluate the agreement and accuracy of prediction equations that estimate the REE in a Mexican population with a diagnosis of HIV/AIDS with and without antiretroviral therapy (ART). METHODS: A cross-sectional study in Mexican patients with HIV/AIDS with and without ART. Weight, height, and body composition measured with dual-energy x-ray absorptiometry were evaluated. The REE was determined with indirect calorimetry and estimated using the Mifflin-St Jeor (MSJ), Harris-Benedict (HB), Schofield 1 and 2, Cunningham, Melchior 91, Melchior 93, and Batterham equations. The Bland-Altman method assessed agreement between the real and estimated values, and the percent difference between these values was used to assess the prediction accuracy. RESULTS: Sixty-five adults without ART and 102 adults with ART were included. The mean REE (kcal/kg) was 24.8 ± 2.4 and 23.8 ± 3.6 in patients without and with ART, respectively. Good agreement and reliability were observed in the HB (intraclass correlation coefficient [ICC], 0.75; P < .05), Batterham (ICC, 0.79; P < .05), Schofield 1 (ICC, 0.74; P < .05), and Schofield 2 (ICC, 0.78; P < .05) results in individuals without ART. In individuals with ART, good agreement and reliability were observed with the HB equation (ICC, 0.76; P < .05). The MSJ equation showed good agreement with poor reliability (ICC, 0.05; P < .05). CONCLUSION: The equations with the best agreement and accuracy were Schofield 2, Batterham, and HB in individuals without ART and HB and MSJ in the population with ART.

Comparison of the Mini-Nutritional Assessment short and long form and serum albumin as prognostic indicators of hip fracture outcomes.

INTRODUCTION: Malnutrition is common among older hip fracture patients and associated with adverse outcomes. We examined Mini Nutritional Assessment short (MNA-SF) and long form (MNA-LF) and serum albumin as prognostic indicators of mobility, living arrangements and mortality after hip fracture. METHODS: Population-based prospective data were collected on 594 hip fracture patients aged 65 and over. MNA-SF, MNA-LF and serum albumin were assessed on admission. Outcomes were poorer mobility; transfer to more assisted living accommodation and mortality one month, four months and one year post fracture. Logistic regression analyses for mobility and living arrangements with odds ratios (OR) and Cox proportional hazards model for mortality with hazard ratios (HR) and 95% confidence intervals (CI) were used, adjusted for age, gender, ASA grade and fracture type. RESULTS: All measures predicted mortality at all time-points. Risk of malnutrition and malnutrition measured by MNA-LF predicted mobility and living arrangements within four months of hip fracture. At one year, risk of malnutrition predicted mobility and malnutrition predicted living arrangements, when measured by MNA-LF. Malnutrition, but not risk thereof, measured by MNA-SF predicted living arrangements at all time-points. None of the measures predicted one-month mobility. CONCLUSIONS: All measures were strong indicators of short- and long-term mortality after hip fracture. MNA-LF was superior in predicting mobility and living arrangements, particularly at four months. All measures were relatively poor in predicting short-term outcomes of mobility and living arrangements.

Nutrition Assessment With Indirect Calorimetry in Patients Evaluated for Left Ventricular Assist Device Implantation.

BACKGROUND: Malnutrition is known to negatively impact the clinical course of advanced heart failure and is associated with increased mortality following left ventricular assist device (LVAD) implantation. Appropriate assessment of nutrition requirements in these patients is critical in their clinical care, yet there has been little discussion on how to best determine resting energy expenditure (REE) in the hospital setting. We investigated the use of indirect calorimetry in a group of patients with advanced heart failure. MATERIALS AND METHODS: Results from preoperative indirect calorimetry testing in 98 patients undergoing evaluation for LVAD candidacy were collected. REE was compared with 10 predictive equations that estimated caloric need based on a range of patient-specific demographic and clinical variables. RESULTS: This study enrolled 22 female and 76 male patients with a mean age of 59.4 ± 12.5 years, body mass index of 29.6 ± 6.0 kg/m(2), and ejection fraction of 19.4 ± 6.6%. The average REE by indirect calorimetry in this group was 1610.0 ± 612.7 kcal/d. All predictive equations significantly overestimated REE. However, those equations intended for use in the critically ill demonstrated the greatest accuracy, with the Brandi equation achieving both the highest correlation (r = 0.605, P < .001) and the lowest standard error of the estimate (504.8 kcal/d). CONCLUSIONS: Indirect calorimetry may be reliably and safely used to determine caloric requirements in patients with advanced heart failure. The use of predictive equations based on demographic and clinical parameters appears to generate inaccurate estimations of REE in these patients. However, equations designed for use in critically ill patients better estimate nutrition requirements than those designed for healthy individuals.

The impact of abdominal aortic aneurysm on muscle mass and energy expenditure: A novel preliminary investigation.

OBJECTIVE: Vascular surgical patients, including those with abdominal aortic aneurysm (AAA), are nutritionally vulnerable. The aim of this study was to compare resting energy expenditure (REE) of patients with AAA relative to age- and gender-matched controls and explore relationships between aneurysm size and muscle mass. METHODS: Twenty patients with AAA underwent assessment of REE using indirect calorimetry. Mid-arm circumference and triceps skinfold thickness were measured and corrected arm muscle area calculated. Twenty gender- and age-matched controls were assessed using the same procedures. RESULTS: Mean (SD) age of participants with AAA was 74.7 (7.7) years, size of AAA ranged from 45 to 70 mm. Median (IQR) REE was significantly higher than controls [5990 (5469, 7017) kJ/day versus 5086 (4536, 5886) kJ/day, p = .011; or 69 (64, 80) kJ/kg/day versus 66 (61, 69) kJ/kg/day, p = .046]. While weight-adjusted REE was independent of aneurysm size (r = .200; p = .397), as aneurysm size increased, weight-adjusted corrected arm muscle area decreased (r = -.576; p = .008). CONCLUSION: The raised REE and decline in muscle mass associated with larger AAA suggest that early detection and attention to nutritional requirements of patients with AAA may be warranted.

An unbiased assessment of the role of imprinted genes in an intergenerational model of developmental programming.

Environmental factors during early life are critical for the later metabolic health of the individual and of future progeny. In our obesogenic environment, it is of great socioeconomic importance to investigate the mechanisms that contribute to the risk of metabolic ill health. Imprinted genes, a class of functionally mono-allelic genes critical for early growth and metabolic axis development, have been proposed to be uniquely susceptible to environmental change. Furthermore, it has also been suggested that perturbation of the epigenetic reprogramming of imprinting control regions (ICRs) may play a role in phenotypic heritability following early life insults. Alternatively, the presence of multiple layers of epigenetic regulation may in fact protect imprinted genes from such perturbation. Unbiased investigation of these alternative hypotheses requires assessment of imprinted gene expression in the context of the response of the whole transcriptome to environmental assault. We therefore analyse the role of imprinted genes in multiple tissues in two affected generations of an established murine model of the developmental origins of health and disease using microarrays and quantitative RT-PCR. We demonstrate that, despite the functional mono-allelicism of imprinted genes and their unique mechanisms of epigenetic dosage control, imprinted genes as a class are neither more susceptible nor protected from expression perturbation induced by maternal undernutrition in either the F1 or the F2 generation compared to other genes. Nor do we find any evidence that the epigenetic reprogramming of ICRs in the germline is susceptible to nutritional restriction. However, we propose that those imprinted genes that are affected may play important roles in the foetal response to undernutrition and potentially its long-term sequelae. We suggest that recently described instances of dosage regulation by relaxation of imprinting are rare and likely to be highly regulated.

Dosing regimens of oral ciprofloxacin for children with severe malnutrition: a population pharmacokinetic study with Monte Carlo simulation.

BACKGROUND: Severe malnutrition is frequently complicated by sepsis, leading to high case fatality. Oral ciprofloxacin is a potential alternative to the standard parenteral ampicillin/gentamicin combination, but its pharmacokinetics in malnourished children is unknown. METHODS: Ciprofloxacin (10 mg/kg, 12 hourly) was administered either 2 h before or up to 2 h after feeds to Kenyan children hospitalized with severe malnutrition. Four plasma ciprofloxacin concentrations were measured over 24 h. Population analysis with NONMEM investigated factors affecting the oral clearance (CL) and the oral volume of distribution (V). Monte Carlo simulations investigated dosage regimens to achieve a target AUC(0-24)/MIC ratio of ≥125. RESULTS: Data comprised 202 ciprofloxacin concentration measurements from 52 children aged 8-102 months. Absorption was generally rapid but variable; C(max) ranged from 0.6 to 4.5 mg/L. Data were fitted by a one-compartment model with first-order absorption and lag. The parameters were CL (L/h) = 42.7 (L/h/70 kg) × [weight (kg)/70](0.75) × [1 + 0.0368 (Na(+) - 136)] × [1 - 0.283 (high risk)] and V (L) = 372 × (L/70 kg) × [1 + 0.0291 (Na(+) - 136)]. Estimates of AUC(0-24) ranged from 8 to 61 mg·h/L. The breakpoint for Gram-negative organisms was <0.06 mg/L with doses of 20 mg/kg/day and <0.125 mg/L with doses of 30 or 45 mg/kg/day. The cumulative fraction of response with 30 mg/kg/day was ≥80% for Escherichia coli, Klebsiella pneumoniae and Salmonella species, but <60% for Pseudomonas aeruginosa. CONCLUSIONS: An oral ciprofloxacin dose of 10 mg/kg three times daily (30 mg/kg/day) may be a suitable alternative antibiotic for the management of sepsis in severely malnourished children. Absorption was unaffected by the simultaneous administration of feeds.

Subjective global assessment of nutritional status in children.

This study was aimed to compare the subjective and objective nutritional assessments and to analyse the performance of subjective global assessment (SGA) of nutritional status in diagnosing undernutrition in paediatric patients. One hundred and forty children (aged 2-12 years) hospitalized consecutively in Tabriz Paediatric Hospital from June 2008 to August 2008 underwent subjective assessment using the SGA questionnaire and objective assessment, including anthropometric and biochemical measurements. Agreement between two assessment methods was analysed by the kappa (κ) statistic. Statistical indicators including (sensitivity, specificity, predictive values, error rates, accuracy, powers, likelihood ratios and odds ratio) between SGA and objective assessment method were determined. The overall prevalence of undernutrition according to the SGA (70.7%) was higher than that by objective assessment of nutritional status (48.5%). Agreement between the two evaluation methods was only fair to moderate (κ = 0.336, P < 0.001). The sensitivity, specificity, positive and negative predictive value of the SGA method for screening undernutrition in this population were 88.235%, 45.833%, 60.606% and 80.487%, respectively. Accuracy, positive and negative power of the SGA method were 66.428%, 56.074% and 41.25%, respectively. Likelihood ratio positive, likelihood ratio negative and odds ratio of the SGA method were 1.628, 0.256 and 6.359, respectively. Our findings indicated that in assessing nutritional status of children, there is not a good level of agreement between SGA and objective nutritional assessment. In addition, SGA is a highly sensitive tool for assessing nutritional status and could identify children at risk of developing undernutrition.

Dietary phosphate assessment in dialysis patients.

Malnutrition is known to be highly prevalent in patients with kidney disease. It is associated with poor clinical prognosis and can result from restricted dietary protein-energy intake. The issue is also compounded by protein wasting that occurs in dialysis patients. In countering malnutrition, an adequate protein intake is essential but limited by its phosphate content. Therefore, an accurate assessment of nutritional status and intake is an important part of the therapeutic strategy for patients on dialysis. Assessing dietary phosphate intake is not straight forward, with many confounding factors requiring consideration. Interview and diet diaries are the preferred means by which dietary intake can be estimated. However, it is evident that these estimates can vary considerably and are subject to underreporting. Moreover, the use of phosphates as additives and their omission from available nutrient databases are significant contributors to this variation and underestimation. This review highlights the main limitations in assessing dietary phosphate intake and introduces the concept of monitoring changes in dietary habit (appetite) as a proxy for dietary protein and energy intake. This review discusses the use of monitoring dietary habit in trials, with phosphate binders as a simple tool to address the possibility that changes to dietary habits may influence phosphate binder efficacy.

Effect of undernutrition in foetal life on energy expenditure during gestation in ewes.

The long-term effect of early life undernutrition on late gestation energy expenditure (EEgest) was investigated in sheep. Ewes were fed either adequate (100%) or restricted (60%) energy and protein during late foetal life as well as during last trimester of gestation later in life, resulting in three groups: Adequate-Adequate (AA, n = 5), Adequate-Restricted (AR, n = 5) and Restricted-Restricted (RR, n = 5). At two weeks pre-partum, EEgest were calculated from respiratory gaseous exchange and nitrogen excreted in urine and further it was partitioned to energy expenditure for conceptus development (EEconceptus) and homeorhetic adaptations in maternal metabolism (EEhomeorhetic). Late gestational energy and protein restriction reduced the EEgest in the AR ewes (4.1 MJ x d(-1)) but not in the RR ewes (5.2 MJ x d(-1)) compared with the AA ewes (6.8 MJ x d(-1)). Based on conceptus-weight, no significant difference was found in EEhomeorhetic among the groups; 172, 175 and 169 kJ/kg x d(-1) in AA, AR and RR ewes, respectively. However, EEconceptus was significantly lower in AR (135 kJ/kg x d(-1)) in comparison with AA (298 kJ/kg x d(-1)) and RR (252 kJ/kg x d(-1)) ewes. In conclusion, exposure nutrient restriction in early life impairs the ability of ewes to respond to nutritional restriction in terms of energy expenditure of gestation.

Total energy expenditure (H218O), physical activity level and milk output of lactating rural Bangladeshi tea workers and nontea workers.

OBJECTIVE: To assess the total daily energy expenditure (TDEE), milk output and physical activity level (PAL) of chronically malnourished lactating women using the doubly labelled water method (DLW). DESIGN: Prospective, longitudinal study designed to assess the extent of malnutrition and energetics of lactating tea workers and nontea workers. SETTING: North-east Bangladesh on women working and living in the same tea estates. SUBJECTS: Of an original cohort of 150 lactating women, 30 were selected to participate in this study when they were at about 12 months postpartum. One mother subsequently dropped out. INTERVENTIONS: On day 1 each women provided a urine sample, was administered a dose of DLW and 6 h later provided another sample. Further urine samples were collected for 21 subsequent days. In addition, every 5 days the mother provided a milk sample and at the same time her baby provided a urine sample. RESULTS: Mean (s.d.) BMI was 17.4 (1.63). Mean TDEE and PAL were significantly higher in workers than nonworkers (8.42 (1.38) and 6.83 (2.09) MJ/day, P = 0.02 and 1.92 (0.34) and 1.59 (0.44), P = 0.03, respectively). Mean milk output was similar in the two groups (672 (180) ml and 749 (189) ml in workers and nonworkers, respectively). CONCLUSIONS: Based on international BMI cutoffs, 79% of mothers were suffering from some degree of chronic energy deficiency. A total of 35% of workers and 17% of nonworkers were engaged in strenuous physical activity. The mean milk output of both workers and nonworkers was not different and was high especially as most of the mothers were about 12 months postpartum. No relationship was found between menses return and any of the variables studied. SPONSORSHIP: World Health Organization, Nestle Foundation, UNICEF.

Assessment by flow cytometry of cytokine production in malnourished children.

Malnutrition in children is associated with an increased risk of infection and death. Multiple abnormalities in the immune response, including cytokine production, in protein energy-malnourished children have been described and could account for the increased severity and frequency of infections. In this study, we used flow cytometry to investigate the effects of malnutrition on the production of cytokines (interleukin-2 [IL-2], gamma interferon [IFN-gamma], IL-4, and IL-10) in CD4+ and CD8+ cells and the activation capability (as indicated by CD69+ and CD25+ cells). CD4+ and CD8+ cells from malnourished children showed increased production of IL-4 and IL-10 cytokines and decreased production of IL-2 and IFN-gamma cytokines compared to that in cells from well-nourished, uninfected and well-nourished, infected children. In addition, malnourished children showed impaired activation capability, since the fluorescence intensity of CD69+ and CD25+ cells was lower than that in cells from well-nourished, uninfected and well-nourished, infected children. These results indicate that malnutrition alters the capacity of CD4+ and CD8+ cells to produce IL-2, IFN-gamma, IL-4, and IL-10 in response to stimulus. We concluded that both cytokine production and activation capacity were impaired in malnourished children. This functional impairment may be involved in the failure to develop a specific immune response and the predisposition to infection in these children.

Nutritional screening and assessment in cancer-associated malnutrition.

Up to 85% of all patients with cancer develop clinical malnutrition, which negatively affects patients' response to therapy, increases the incidence of treatment-related side effects and can decrease survival. Early identification of patients who are malnourished or at risk of malnutrition can promote recovery and improve prognosis. In addition, early nutritional intervention is cost effective, as it reduces complication rates and length of hospital stay. The development and use of screening and assessment tools is essential for effective nutritional intervention and management of patients with cancer. Nutritional screening aims to identify patients who are malnourished or at significant risk of malnutrition. Patients identified through screening require referral to a dietician or specialist in nutrition for an in-depth nutritional assessment, involving examination of medical, dietary, psychological and social history, physical examination, anthropometry and biochemical testing. Interventions initiated after nutritional assessment should be tailored to the individual and take into consideration the patient's prognosis. Nutritional care is a fundamental aspect of nursing practice and nurses are ideally placed to play an essential role in the early detection and screening of malnutrition in patients with cancer.

Nutrition assessment of the critically ill adult.

Illness and injury are physiologic stressors that alter the body's metabolic and energy demands. Approximately 30 to 55% of hospitalized patients have evidence of malnutrition, which makes nutrition screening and assessment an integral part of the evaluation of the critically ill adult. Nutritional assessment relies on a complete history and physical examination, appropriate laboratory measurements, and diagnostic testing as warranted. Although a single laboratory result may be helpful for nutritional screening, there is no single parameter that is both sensitive and specific for the diagnosis of malnutrition. Instead, nutritional assessment must be ongoing and be derived from a variety of sources in order to identify nutritional trends over time. Early identification and nutritional intervention can lessen morbidity and mortality risks; however, underlying acute and/or chronic disease processes often need to be identified and corrected before the body can reverse abnormal nutrient metabolism. A comprehensive nutritional assessment, incorporated with clinical status, will provide the basis for a nutritional support plan and evaluation strategies. In order to help the advanced practice nurse determine the appropriate nutritional regimen, this article discusses the importance of the patient history, physical examination, body composition measurement techniques, and laboratory data assessment.

Midarm computerized tomography fat, muscle and total areas correlation with nutritional assessment data.

BACKGROUND AND OBJECTIVES: Correlated nutritional assessment data (anthropometric, bioimpedance and biochemical) with computerized tomography (CT) of total, muscle and fat midarm areas. Total body fat and fat-free mass were estimated using bioimpedance. Daily urinary urea and creatinine were also quantified. In all, 28 subjects (13 males, 15 females) were evaluated and, they were clinically divided in obese, malnourished and control subjects. DESIGN: Quantification of total, fat muscle midarm areas by tomography and anthropometry and total body fat and free-fat mass by bioimpedance. RESULTS: CT values were 29% higher for fat area and 4-5% lower for total and muscle midarm areas compared against anthropometric data. The midarm skinfold thickness highly correlated with CT fat midarm area. Total body fat and free-fat mass bioimpedance data showed significant correlation with CT midarm data. Urinary creatinine correlated with CT muscle midarm area. CONCLUSION: Utilization of anthropometry can lead to error estimation of fat and fat-free arm areas and that bioimpedance gives fair correlation between total body and CT midarm measurements.