Maintenance of Skeletal Muscle to Counteract Sarcopenia in Patients with Advanced Chronic Kidney Disease and Especially Those Undergoing Hemodialysis.

Life extension in modern society has introduced new concepts regarding such disorders as frailty and sarcopenia, which has been recognized in various studies. At the same time, cutting-edge technology methods, e.g., renal replacement therapy for conditions such as hemodialysis (HD), have made it possible to protect patients from advanced lethal chronic kidney disease (CKD). Loss of muscle and fat mass, termed protein energy wasting (PEW), has been recognized as prognostic factor and, along with the increasing rate of HD introduction in elderly individuals in Japan, appropriate countermeasures are necessary. Although their origins differ, frailty, sarcopenia, and PEW share common components, among which skeletal muscle plays a central role in their etiologies. The nearest concept may be sarcopenia, for which diagnosis techniques have recently been reported. The focus of this review is on maintenance of skeletal muscle against aging and CKD/HD, based on muscle physiology and pathology. Clinically relevant and topical factors related to muscle wasting including sarcopenia, such as vitamin D, myostatin, insulin (related to diabetes), insulin-like growth factor I, mitochondria, and physical inactivity, are discussed. Findings presented thus far indicate that in addition to modulation of the aforementioned factors, exercise combined with nutritional supplementation may be a useful approach to overcome muscle wasting and sarcopenia in elderly patients undergoing HD treatments.

[Characteristics of the metabolic status of children of the first year of life with protein-energy deficiency depending on the gestational age at birth.] / Характеристика метаболического статуса детей первого года жизни с белково-энергетической недостаточностью в зависимости от гестационного возраста при рождении.

Comparative analysis of energy-plastic exchange indicators in mature and premature children of the first year of life in the development of protein-energy malnutrition (PEM) was carried out. Unidirectional changes are revealed, including an increase in creatinine, lactate and creatine phosphokinase activity levels, suggesting a n increasing muscle mass deficit against the background of glucose anaerobic oxidation activation. In preterm infants, glucose and triacylglicerine levels decrease, which reflects uncompensated insufficiency of energy substrates and, accordingly, ATP level. Multidirectional deviations in metabolism are pyruvate and ATP content: increase in full-term infants and decrease in preterm infants, that should be taken into account when monitoring condition of children with PEM. A significant decrease of pyruvic acid in preterm infants against the background of the levels of total protein, albumin, hemoglobin, and transferrin, not exceeding reference values, can obviously testify to the active use of this integral metabolite to maintain the fund of substituted amino acids. Development of this pathology in both mature and premature infants creates a pre-morbid background for iron deficiency anemia-diagnostic panel, which should be supplemented by calculation of transferrin saturation coefficient. Regardless of gestational age in childbirth during the formation of PEM, the lipid spectrum is rearranged according to atherogenic type: at normal values of total cholesterol, there is a significant increase in low and very low density lipoproteins with an increase in the atherogenicity coefficient. This singles out children with the pathology in question as a risk group for the development of the atherosclerotic process later, which justifies the recommendation to control the lipid profile in children of the first year of life.

Cachexia/Protein energy wasting syndrome in CKD: Causation and treatment.

Cachexia is a multifactorial syndrome defined by significant body weight loss, fat and muscle mass reduction, and increased protein catabolism. Protein energy wasting (PEW) is characterized as a syndrome of adverse changes in nutrition and body composition being highly prevalent in patients with CKD, especially in those undergoing dialysis, and it is associated with high morbidity and mortality in this population. Multiple mechanisms are involved in the genesis of these adverse nutritional changes in CKD patients. There is no obvious distinction between PEW and cachexia from a pathophysiologic standpoint and should be considered as part of the spectrum of the same nutritional disorder in CKD with similar management approaches for prevention and treatment based on current understanding. A plethora of factors can affect the nutritional status of CKD patients requiring a combination of therapeutic approaches to prevent or reverse protein and energy depletion. At present, there is no effective pharmacologic intervention that prevents or attenuates muscle atrophy in catabolic conditions like CKD. Prevention and treatment of uremic muscle wasting involve optimal nutritional support, correction of acidosis, and physical exercise. There has been emerging consistent evidence that active treatment, perhaps by combining nutritional interventions and resistance exercise, may be able to improve but not totally reverse or prevent the supervening muscle wasting and weakness. Active research into more direct pharmacological treatment based on basic mechanistic research is much needed for this unmet medical need in patients with CKD.

Nutritional Assessment of Dialysis Patient with a Web-Based Tool Allows More Accurate Treatment of Malnutrition.

BACKGROUND/AIMS: Regular assessment of nutritional status of dialysis patients is vital for preventing malnutrition and protein energy wasting. The aim of this clinical study was to analyze dietary intake of dialysis patients and to determine if it meets their nutritional needs. METHODS: Clinical study was conducted on 30 randomly selected dialysis patients in the dialysis department of the University Medical Centre Ljubljana. Nutritional interview was conducted unannounced five times over a period of three months with the 24-hour recall method. Results were analyzed with Prodi 6.6 Expert software. Body composition was measured with bioimpedance spectroscopy. RESULTS: Average caloric intake of 30 patients is 14.1 ± 4.7 kcal/kg body weight per day, average protein intake is 0.61 ± 0.19 g/kg body weight per day. The average BMI (body mass index) is 27.9 ± 4.4 kg/m2, the average LTI (lean tissue index) is 12.5 ± 3.1 kg/m2, the average FTI (fat tissue index) is 14.2 ± 5.7 kg/m2 and the average phase angle is 4.2 ± 1.0. Average calorie intake and protein intake are inadequate according to the dietary recommendations for dialysis patients. Anthropometric measurements indicate sarcopenic obesity. CONCLUSION: According to the aim of the study, we confirmed that caloric and protein intake of dialysis patients were inadequate according to their needs. Depending on the results of nutritional analysis and bioimpedance measurements, we have confirmed the presence of protein energy wasting among observed patients.

Protein blend ingestion before allogeneic stem cell transplantation improves protein-energy malnutrition in patients with leukemia.

Severe protein-energy malnutrition (PEM) and skeletal muscle wasting are commonly observed in patients with acute leukemia. Recently, the ingestion of a soy-whey protein blend has been shown to promote muscle protein synthesis (MPS). Thus, we tested the hypothesis that the ingestion of a soy-whey blended protein (BP) may improve the PEM status and muscle mass in acute leukemia patients. In total, 24 patients from the same treatment group were randomly assigned to the natural diet plus soy-whey blended protein (BP) group and the natural diet only (ND) group. Our data showed that protein and energy intake decreased significantly (P < .05) after transplantation in both groups. In the absence of the BP intervention, dramatic decreases in muscle-related indicators (i.e., anthropometric variables, muscle strength and serum protein) were observed in the majority (>50%) of the patients. However, 66% of the patients who ingested the BP before transplantation showed obvious increases in arm muscle area. The gripping power value (△post-pre or △post-baseline) was significantly higher in the BP group than in the ND group (P < .05). The ingestion of the BP also increased the levels of serum albumin, globulin and serum total protein to different extents. Notably, the average time to stem cell engraftment was significantly shorter for patients in the BP group (12.2 ± 2.0 days) than for patients in the ND group (15.1 ± 2.9 days). Collectively, our data supported that soy-whey protein can improve PEM status and muscle mass in leukemia patients.

Protein-calorie malnutrition, macronutrient supplements, and tuberculosis.

BACKGROUND: Protein-calorie malnutrition (PCM) is a risk factor for tuberculosis (TB) disease and may affect treatment outcomes. There is currently no recommended macronutrient intervention for improving the outcome of anti-tuberculosis treatment. METHODS: We reviewed current literature on PCM and low body mass index (BMI) as risk factors for tuberculous infection and TB disease, and their effects on anti-tuberculosis treatment. We summarize clinical trials of macronutrient supplementation in the treatment of TB. RESULTS: PCM is a well-established risk factor for TB disease; however, data on malnutrition and the risk of tuberculous infection are limited. Malnutrition is associated with an increased risk of mortality and relapse of active TB. Clinical trials of macronutrient supplementation during treatment confirm a 2-3 kg improvement in weight gain at 2 months, and may result in improvement in physical function, sputum conversion and treatment completion, but they have not been powered to assess effects on mortality or relapse. CONCLUSION: Assessment of dietary intake, food security, and baseline BMI should be standard practice in anti-tuberculosis treatment, along with dietary counselling. As macronutrient supplementation may have modest benefits and is not associated with adverse events, patients with BMI values <18.5 kg/m(2) should be provided with balanced macronutrient supplementation whenever possible.

Selenium in dysphagic patients who underwent endoscopic gastrostomy for long term enteral feeding / Selenio sérico en pacientes con disfagia sometidos a gastrostomía endoscópica percutánea para nutrición enteral prolongada

Background and aims: endoscopic gastrostomy (PEG) patients usually present protein-energy malnutrition, but little is known about selenium deficiency. We aimed to assess serum selenium evolution when patients underwent PEG, after 4 and 12 weeks. We also evaluated the evolution of albumin, transferrin and Body Mass Index and the influence of the nature of the underlying disease. Methods: a blood sample was obtained before PEG (T0), after 4 (T1) and 12 (T3) weeks. Selenium was assayed using GFAAS (Furnace Atomic Absorption Spectroscopy). The PEG patients were fed through homemade meals. Patients were studied as a whole and divided into two groups: head and neck cancer (HNC) and neurological dysphagia (ND). Results: we assessed 146 patients (89 males), between 21-95 years old: HNC-56; ND-90. Normal values of selenium in 79% (n=115); low albumin in 77, low transferrin in 94, low values for both serum proteins in 66. Low BMI in 78. Selenium has slow evolution, with most patients still displaying normal Selenium at T3 (82%). Serum protein levels increase from T0 to T3, most patients reaching normal values. The nature of the underlying disease is associated with serum proteins but not with selenium. Conclusions: low serum selenium is uncommon when PEG is performed, after 4 and 12 weeks of enteral feeding and cannot be related with serum proteins levels or dysphagia cause. Enteral nutrition using customized homemade kitchen meals is satisfactory to prevent or correct Selenium deficiency in the majority of PEG patients (AU)

Introducción y objetivos: los pacientes con gastrostomía endoscópica (GEP) presentan malnutrición calórica-proteica, pero poco se conoce sobre la deficiencia de selenio. Estudiamos la evolución del selenio sérico en el momento de la GEP y después 4 y 12 semanas. Además, evaluamos la evolución de albúmina, transferrina, índice de masa corporal (IMC) y la influencia de la enfermedad subyacente. Métodos: obtenemos una muestra de sangre antes de la gastrostomía (T0), y después de 4 (T1) y 12 (T3) semanas. El selenio fue valorado mediante GFAAS (Furnace Atomic Absorption Spectroscopy). Los enfermos consumieron alimentos de preparación doméstica. Los pacientes fueron estudiados como un grupo y después separados en dos grupos: cánceres de cabeza y cuello (CCC) y disfagia neurológica (DN). Resultados: 146 enfermos (89 hombres), entre 21-95 años: CCC-56, DN-90. Valores normales de selenio en 79% (n=115), albúmina baja: 77 enfermos, transferrina baja: 94, las dos proteínas bajas: 66, IMC bajo: 78. El selenio ha demostrado una evolución lenta en el 82% de los enfermos presentando selenio normal en T3. Las proteínas séricas incrementaron sus valores en T0-T3, la mayoría de los enfermos alcanzó niveles normales. La enfermedad subyacente, CCC o DN, se relacionó con las proteínas, pero no con el selenio. Conclusiones: el selenio sérico bajo es poco común antes de la gastrostomía; después de 4 y 12 semanas de nutrición enteral no tiene relación con las proteínas séricas ni con la enfermedad que causa la disfagia. La nutrición con alimentación de preparación doméstica es suficiente para prevenir o corregir la deficiencia de selenio de la mayoría de los enfermos (AU)

A cluster randomised feasibility trial evaluating nutritional interventions in the treatment of malnutrition in care home adult residents.

BACKGROUND: Protein energy malnutrition (PEM) predisposes individuals to disease, delays recovery from illness and reduces quality of life. Care home residents in the United Kingdom are especially vulnerable, with an estimated 30 to 42 % at risk. Evidence for nutritional interventions to address PEM in the care home setting is lacking. Widely used techniques include food-based intervention and/or the use of prescribed oral nutritional supplements. To define outcomes and optimise the design for an adequately powered definitive trial to compare the efficacy of established nutritional interventions in this setting, a cluster randomised feasibility trial with a 6-month intervention was undertaken. METHODS: Care home residents with or at risk of malnutrition were identified across six UK care home sites from September to December 2013. Homes were cluster randomised to standard care (SC), food-based intervention (FB) or oral nutritional supplement intervention (ONS), for 6 months. Key outcomes were trial feasibility and the acceptability of design, allocated interventions and outcome assessments. Anthropometry, dietary intake, healthcare resource usage and participant-reported outcome measures were assessed at baseline and at 3 and 6 months. RESULTS: All six care homes approached were recruited and retained. Of the 110 residents at risk of malnutrition, 85 % entered the trial, and 68 % completed the 6-month intervention. Pre-specified success criteria for feasibility were met for recruitment and retention, intervention acceptability (resident compliance ≥60 %) and measurement of weight, body mass index (BMI), mid-upper arm circumference and dietary intake (data completeness >80 %). Measurement of handgrip strength and triceps skinfold thickness was not found to be feasible in this population. The 95 % confidence interval (CI) data suggested sensitivity to change in dietary intake for weight, BMI and energy intake between baseline and 3 months when each intervention (FB and ONS) was compared with SC. CONCLUSIONS: A definitive trial comparing the efficacy of nutritional support interventions in increasing weight and BMI in malnourished care home residents can be conducted. However, whilst the design was feasible, this trial has highlighted the lack of clinically and patient-relevant outcome measures that are appropriate for use in this setting for both research and clinical practice. In particular, this trial identified a need for a more simple measure of functional status, which considers the limitations of functional tests in the care home population. TRIAL REGISTRATION: Current Controlled Trials ISRCTN38047922 , Date assigned: 22 April 2014.

Effects of a vitamin D and leucine-enriched whey protein nutritional supplement on measures of sarcopenia in older adults, the PROVIDE study: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Age-related losses of muscle mass, strength, and function (sarcopenia) pose significant threats to physical performance, independence, and quality of life. Nutritional supplementation could positively influence aspects of sarcopenia and thereby prevent mobility disability. OBJECTIVE: To test the hypothesis that a specific oral nutritional supplement can result in improvements in measures of sarcopenia. DESIGN: A multicenter, randomized, controlled, double-blind, 2 parallel-group trial among 380 sarcopenic primarily independent-living older adults with Short Physical Performance Battery (SPPB; 0-12) scores between 4 and 9, and a low skeletal muscle mass index. The active group (n = 184) received a vitamin D and leucine-enriched whey protein nutritional supplement to consume twice daily for 13 weeks. The control group (n = 196) received an iso-caloric control product to consume twice daily for 13 weeks. Primary outcomes of handgrip strength and SPPB score, and secondary outcomes of chair-stand test, gait speed, balance score, and appendicular muscle mass (by DXA) were measured at baseline, week 7, and week 13 of the intervention. RESULTS: Handgrip strength and SPPB improved in both groups without significant between-group differences. The active group improved more in the chair-stand test compared with the control group, between-group effect (95% confidence interval): -1.01 seconds (-1.77 to -0.19), P = .018. The active group gained more appendicular muscle mass than the control group, between-group effect: 0.17 kg (0.004-0.338), P = .045. CONCLUSIONS: This 13-week intervention of a vitamin D and leucine-enriched whey protein oral nutritional supplement resulted in improvements in muscle mass and lower-extremity function among sarcopenic older adults. This study shows proof-of-principle that specific nutritional supplementation alone might benefit geriatric patients, especially relevant for those who are unable to exercise. These results warrant further investigations into the role of a specific nutritional supplement as part of a multimodal approach to prevent adverse outcomes among older adults at risk for disability.

An innovative solid oral nutritional supplement to fight weight loss and anorexia: open, randomised controlled trial of efficacy in institutionalised, malnourished older adults.

BACKGROUND AND OBJECTIVE: To evaluate the impact of a solid nutritional supplement on the weight gain of institutionalised older adults>70 years with protein-energy malnutrition. The innovation of these high-protein and high-energy cookies was the texture adapted to edentulous patients (Protibis®, Solidages, France). DESIGN: An open, multicentre, randomised controlled trial. SETTING: Seven nursing homes. PARTICIPANTS: One hundred and seventy-five malnourished older adults, aged 86±8 years. INTERVENTION: All participants received the standard institutional diet. In addition, Intervention group participants received eight cookies daily (11.5 g protein; 244 kcal) for 6 weeks (w0-w6). MEASUREMENTS: Five visits (w-4, w0, w6, w10 and w18). MAIN OUTCOME: Percentage of weight gain from w0 to w6 (body mass in kg). SECONDARY OUTCOMES: Appetite, rated using a numerical scale (0: no appetite to 10: extremely good appetite); current episodes of pressure ulcers and diarrhea. RESULTS: Average weight increased in Intervention group (n=88) compared with Control group (n=87) without cookies supplementation (+1.6 versus -0.7%, P=0.038). Weight gain persisted 1 month (+3.0 versus -0.2%, P=0.025) and 3 months after the end of cookies consumption (+3.9 versus -0.9%, P=0.003), with diarrhea reduction (P=0.027). There was a synergistic effect with liquid/creamy dietary supplements. Subgroup analysis confirmed the positive impact of cookies supplementation alone on weight increase (P=0.024), appetite increase (P=0.009) and pressure ulcers reduction (P=0.031). CONCLUSION: The trial suggested that, to fight against anorexia, the stimulation of touch (finger food; chewing, even on edentulous gums) and hearing (intra-oral sounds) could be valuable alternatives to sight, smell and taste alterations.

Bee pollen improves muscle protein and energy metabolism in malnourished old rats through interfering with the Mtor signaling pathway and mitochondrial activity.

Although the management of malnutrition is a priority in older people, this population shows a resistance to refeeding. Fresh bee pollen contains nutritional substances of interest for malnourished people. The aim was to evaluate the effect of fresh bee pollen supplementation on refeeding efficiency in old malnourished rats. Male 22-month-old Wistar rats were undernourished by reducing food intake for 12 weeks. The animals were then renourished for three weeks with the same diet supplemented with 0%, 5% or 10% of fresh monofloral bee pollen. Due to changes in both lean mass and fat mass, body weight decreased during malnutrition and increased after refeeding with no between-group differences (p < 0.0001). Rats refed with the fresh bee pollen-enriched diets showed a significant increase in muscle mass compared to restricted rats (p < 0.05). The malnutrition period reduced the muscle protein synthesis rate and mTOR/p70S6kinase/4eBP1 activation, and only the 10%-pollen diet was able to restore these parameters. Mitochondrial activity was depressed with food restriction and was only improved by refeeding with the fresh bee pollen-containing diets. In conclusion, refeeding diets that contain fresh monofloral bee pollen improve muscle mass and metabolism in old, undernourished rats.

Nutrition and exercise in the management of liver cirrhosis.

Liver cirrhosis (LC) patients often have protein-energy malnutrition (PEM) and decreased physical activity. These conditions often lead to sarcopenia, which is the loss of skeletal muscle volume and increased muscle weakness. Recent studies have demonstrated that PEM and sarcopenia are predictors for poor survival in LC patients. Nutrition and exercise management can improve PEM and sarcopenia in those patients. Nutrition management includes sufficient dietary intake and improved nutrient metabolism. With the current high prevalence of obesity, the number of obese LC patients has increased, and restriction of excessive caloric intake without the exacerbation of impaired nutrient metabolism is required for such patients. Branched chain amino acids are good candidates for supplemental nutrients for both obese and non-obese LC patients. Exercise management can increase skeletal muscle volume and strength and improve insulin resistance; however, nutritional status and LC complications should be assessed before an exercise management regimen is implemented in LC patients. The establishment of optimal exercise regimens for LC patients is currently required. In this review, we describe nutritional status and its clinical impact on the outcomes of LC patients and discuss general nutrition and exercise management in LC patients.

[Anorexia nervosa - from a neuroscience perspective]. / Anorexia nervosa. Aktuelle neurowissenschaftliche Befunde.

Anorexia nervosa is a frequent disorder especially among adolescent girls and young women, with high morbidity, mortality, and relapse rates. To date, no single therapeutic approach has proved to be superior to others (Herpertz et al., 2011). It remains unclear how its etiology and pathology are encoded within cognitive, neural, and endocrinological processes that modulate important mechanisms in appetitive processing and weight regulation. Yet, several trait characteristics have been identified in AN which might reflect predisposing factors. Further, altered levels of neuropeptides and hormones that regulate appetite and feeding behavior have been found during both the acute and the recovered state, pointing to dysfunctional mechanisms in AN that persist even after malnutrition has ceased. Researchers are also hoping that brain imaging techniques will allow for a more detailed investigation of the neural basis of reward and punishment sensitivity that appears to be altered in AN. The integration and extension of recent findings in these areas will hopefully provide a more comprehensive understanding of the disorder and hence enable the development of more effective treatments.

[Food supplements--potential and limits: part 3]. / Nährstoffsupplemente--Möglichkeiten und Grenzen. Teil 3: Supplemente im höheren Lebensalter.

Ageing processes are associated with physiological changes, e.g. a reduction of metabolically active body mass and an impaired hunger-satiety regulation, which--combined with chronic diseases and psychosocial problems--significantly increase the risk for malnutrition. However, considering their nutrition and health status elderly people are a very heterogeneous group. The nutrition situation of "young" seniors does generally not differ from the situation of working-age adults while institutionalized elderly people and those in need of care often show signs of a global malnutrition. The critical nutrients in the nutrition of the elderly particularly include vitamin B12 and D. Six percent of all elderly have a manifest and 10 to 30% a functional vitamin B12 deficiency. The main cause is vitamin B12 malabsorption resulting from a type B atrophic gastritis. The functional vitamin B12 deficiency and the associated hyperhomocysteinemia are risk factors for neurodegenerative diseases and accelerate bone loss. With increasing age the vitamin D status is deteriorating. About 50% of the elderly living in private households is deficient in vitamin D; in geriatrics vitamin D deficiency is more the rule than an exception. This is caused by a reduced endogenous biosynthesis, low UVB exposure and a diet low in vitamin D. A vitamin D deficiency increases the risk for falls and fractures as well as the risk for neurodegenerative diseases. Also the overall mortality is increased.

Cancer cachexia pathophysiology and translational aspect of herbal medicine.

About half of all cancer patients show a syndrome of cachexia, characterized by anorexia and loss of adipose tissue and skeletal muscle mass. Numerous cytokines have been postulated to play a role in the etiology of cancer cachexia. Cytokines can elicit effects that mimic leptin signaling and suppress orexigenic ghrelin and neuropeptide Y signaling, inducing sustained anorexia and cachexia not accompanied by the usual compensatory response. Furthermore, cytokines have been implicated in the induction of cancer-related muscle wasting. In particular, tumor necrosis factor-alpha, interleukin-1, interleukin-6 and interferon-gamma have been implicated in the induction of cancer-related muscle wasting. Cytokine-induced skeletal muscle wasting is probably a multifactorial process, which involves a depression in protein synthesis, an increase in protein degradation or a combination of both. Cancer patients suffer from the reduction in physical function, tolerance to anti-cancer therapy and survival, while many effective chemotherapeutic agents for cancer are burdened by toxicities that can reduce patient's quality of life or hinder their effective use. Herbal medicines have been widely used to help improve such conditions. Recent studies have shown that herbal medicines such as rikkunshito enhance ghrelin signaling and consequently improve nausea, appetite loss and cachexia associated with cancer or cancer chemotherapy, which worsens the quality of life and life expectancy of the patients. The multicomponent herbal medicines capable of targeting multiple sites could be useful for future drug discovery. Mechanistic studies and identification of active compounds could lead to new discoveries in biological and biomedical sciences.

Nutritional approaches in the risk reduction and management of Alzheimer's disease.

Alzheimer's disease (AD) is a heterogeneous and devastating neurodegenerative disease with increasing socioeconomic burden for society. In the past 30 y, notwithstanding advances in the understanding of the pathogenesis of the disease and consequent development of therapeutic approaches to novel pathogenic targets, no cure has so far emerged. This contribution focuses on recent nutritional approaches in the risk reduction and management of AD with emphasis on factors providing a rationale for nutritional approaches in AD, including compromised nutritional status, altered nutrient uptake and metabolism, and nutrient requirements for synapse formation. Collectively these factors are believed to result in specific nutritional requirement in AD. The chapter also emphasizes investigated nutritional interventions in patients with AD, including studies with single nutrients and with the specific nutrient combination Fortasyn Connect and discusses the current shift of paradigm to intervene in earlier stages of AD, which offers opportunities for investigating nutritional strategies to reduce the risk for disease progression. Fortasyn Connect was designed to enhance synapse formation and function in AD by addressing the putative specific nutritional requirements and contains docosahexaenoic acid, eicosapentaenoic acid, uridine-5'-mono-phosphate, choline, phospholipids, antioxidants, and B vitamins. Two randomized controlled trials (RCTs) with the medical food Souvenaid, containing Fortasyn Connect, showed that this intervention improved memory performance in mild, drug-naïve patients with AD. Electroencephalography outcome in one of these clinical studies suggests that Souvenaid has an effect on brain functional connectivity, which is a derivative of changed synaptic activity. Thus, these studies suggest that nutritional requirements in AD can be successfully addressed and result in improvements in behavioral and neuro-physiological alterations that are characteristic to AD. The recent advance of methodologies and techniques for early diagnosis of AD facilitates the investigation of strategies to reduce the risk for AD progression in the earliest stages of the disease. Nutrition-based approaches deserve further investigation as an integral part of such strategies due to their low risk for side effects and their potential to affect pathological processes of very early AD.

Thailand nutrition in transition: situation and challenges of maternal and child nutrition.

Double burden of malnutrition (DBMN), the coexistence of under- and overnutrition in the same population, is an emerging public health concern in developing countries, including Thailand. This paper aims to review the maternal and child nutrition situation and trends as the country moved from a low-income to a middle-income country, using data from large scale national surveys. Protein-energy malnutrition and micronutrient deficiencies predominantly affected mothers and children prior to the 1980s. The situation greatly improved during the 1980s- 1990s, with the implementation of multi-sectoral policies and programs focusing on poverty alleviation and primary health care. Economic development, improved access to health services and effective community-based nutrition programs contributed to these positive trends. However, the prevalence of low birth weight remained at 8- 10%, while stunting and underweight declined to about 10% by the 1990s, with small change thereafter. The prevalence of anemia among pregnant women and children decreased by half and vitamin A deficiency is no longer a public health problem. Iodine deficiency, especially during pregnancy is still a major concern. As the country progressed in terms of economic and social development, overnutrition among women and children affected all socio-economic levels. Changes in lifestyles, food access and eating patterns are observed both in urban and rural areas. Although efforts have been made to address these challenges, harmonized policy and strategic programs that address DBMN in the complex social and economic environment are urgently needed. Early life undernutrition should be considered along with measures to address obesity and chronic diseases in children.

Nutrition and skin ulcers.

PURPOSE OF REVIEW: Skin ulcerations cause significant morbidity and mortality, while driving up healthcare utilization and costs. Interventions to prevent ulcers and improve wound healing times are needed to reduce the burden on patients and healthcare systems. It has been well established that weight loss, protein-calorie malnutrition, and dehydration are risk factors for pressure ulcers. Many nutritional interventions have been studied, with studies being of variable quality and producing mixed results. This review aims to clarify the current evidence and highlights the recent advances in the area of nutrition for the prevention and management of skin ulceration. RECENT FINDINGS: Markers for assessing nutritional status will be reviewed first, followed by a discussion on the theoretical benefit of various nutritional interventions on wound healing. Recommendations for nutrient repletion are also included. Finally, the most recent or important literature will be highlighted and the risks and benefits of supplementation are debated. There is mixed evidence for most nutritional interventions, with most studies being of poor quality with variable study designs, lack of control groups, small sample sizes, and short study lengths. SUMMARY: Long-term randomized trials of individual nutrients and clinically relevant endpoints are needed to definitively show the benefit of additional nutritional supplementation over dietary interventions. Until those studies become available, best evidence suggests the importance of screening for malnutrition, calculating resting energy expenditure and caloric needs, and monitoring dietary intake of essential nutrients.

Nutritional imbalances and infections affect the thymus: consequences on T-cell-mediated immune responses.

The thymus gland, where T lymphocyte development occurs, is targeted in malnutrition secondary to protein energy deficiency. There is a severe thymic atrophy, resulting from massive thymocyte apoptosis (particularly affecting the immature CD4+CD8+ cell subset) and decrease in cell proliferation. The thymic microenvironment (the non-lymphoid compartment that drives intrathymic T-cell development) is also affected in malnutrition: morphological changes in thymic epithelial cells were found, together with a decrease of thymic hormone production, as well as an increase of intrathymic contents of extracellular proteins. Profound changes in the thymus can also be seen in deficiencies of vitamins and trace elements. Taking Zn deficiency as an example, there is a substantial thymic atrophy. Importantly, marginal Zn deficiency in AIDS subjects, children with diarrhoea and elderly persons, significantly impairs the host's immunity, resulting in an increased risk of opportunistic infections and mortality; effects that are reversed by Zn supplementation. Thymic changes also occur in acute infectious diseases, including a severe thymic atrophy, mainly due to the depletion of CD4+CD8+ thymocytes, decrease in thymocyte proliferation, in parallel to densification of the epithelial network and increase in the extracellular matrix contents, with consequent disturbances in thymocyte migration and export. In conclusion, the thymus is targeted in several conditions of malnutrition as well as in acute infections. These changes are related to the impaired peripheral immune response seen in malnourished and infected individuals. Thus, strategies inducing thymus replenishment should be considered as adjuvant therapeutics to improve immunity in malnutrition and/or acute infectious diseases.