Translation into Brazilian Portuguese and transcultural adaptation and validation of the treatment specific questionnaire Home Parenteral Nutrition- Quality of Life (HPN-QOL©).

BACKGROUND & AIMS: Home Parenteral Nutrition (HPN) is the main treatment for patients with chronic intestinal failure. It is commonly prescribed for nutritional recovery, survival increase and, whenever possible, improvement of quality of life. As there are no validated instruments in Brazilian Portuguese to be used in these patients, the objective of this study was to carry out the transcultural adaptation and validation of Home Parenteral Nutrition - Quality of life (HPN-QOL©) into Brazilian Portuguese. METHODS: This observational and cross-sectional study was conducted at the multidisciplinary short-bowel syndrome clinic (AMULSIC) of the Hospital das Clínicas of the University of São Paulo Medical School (HC-FMUSP). A five-stage protocol was adopted for the transcultural adaptation: initial translation; synthesis; reverse translation; experts committee and pre-test. The adapted questionnaire was applied to a convenience (representative) sample (n = 16) and Cronbach's Alpha Coefficient, Intraclass Correlation Coefficient (ICC), and Bland-Altman Test were submitted for the analysis of the internal consistency and intraobserver and interobserver reproducibility. RESULTS: The transcultural adaptation was considered excellent (Content Validity Index = 100%). The internal consistency was satisfactory for most of the scales (16/19), and α > 0.70 was 84.21%. ICC values revealed high intraobserver and interobserver reproducibility in most of the scales. No significant difference was observed between intraobservers and interobservers in any of the questions (p > 0.05). CONCLUSIONS: The questionnaire was shown as adapted and valid for use in Brazil. Future trials with a higher sample are yet to be developed to shed light on specific scales that were inconsistent. It's expected that this would contribute for the usual quality of life assessment for individuals treated with HPN in Brazil.

BONE HEALTH ASSESSMENT OF ELDERLY PATIENTS UNDERGOING BARIATRIC SURGERY.

BACKGROUND: Bariatric surgery promotes changes in body composition, that can include the loss of bone mineral density (BMD). There is a lack of studies on the evolution of bone health of elderly people who underwent bariatric surgery, in general, and when comparing the gastric bypass (GB) and sleeve gastrectomy (SG) techniques. OBJECTIVE: To evaluate the bone health of elderly patients with obesity undergoing bariatric surgery. METHODS: This is a prospective randomized clinical study, that was carried out with individuals of both sexes, ≥65 years, undergoing GB or SG and who met the inclusion criteria. Age, gender and comorbidities (type 2 diabetes mellitus, arterial hypertension, dyslipidemia and osteoarthrosis) were collected and analyzed at baseline. Anthropometric data (weight, body mass index, percentage of weight loss, percentage of excess weight loss), laboratory tests related to bone health and bone mineral density were analyzed before and 24 months after surgery. RESULTS: A total of 36 patients (GB, n=18; SG, n=18) were evaluated. At baseline, except for sex and preoperative body mass index, which was higher in GB, groups were similar. After 24 months, GB was superior for weight loss (%WL) and excess weight loss (%EWL). Regarding bone health, a significant decrease of BMD was observed in the spine, total proximal femur and femoral neck in all groups, with an average decrease of 5.1%, 10.5% and 15.1%, respectively. In addition, the observed decrease in BMD was up to 25% in the total femur after 24 months, six patients went from normal BMD to osteopenia and one from osteopenia to osteoporosis. There was no difference in parathormone values. However, there was an association between the increase in parathormone and the decrease in BMD in the spine, mainly in the GB group. There was no association between %WL and %EWL with the reduction in BMD. CONCLUSION: Bariatric surgery was related to the reduction of BMD in elderly patients, but there was no statistical difference between the two surgical techniques.

Avaliação da saúde óssea de pacientes idosos submetidos a cirurgia bariátrica / Bone health assessment of elderly patients undergoing bariatric surgery

ABSTRACT Background: Bariatric surgery promotes changes in body composition, that can include the loss of bone mineral density (BMD). There is a lack of studies on the evolution of bone health of elderly people who underwent bariatric surgery, in general, and when comparing the gastric bypass (GB) and sleeve gastrectomy (SG) techniques. Objective: To evaluate the bone health of elderly patients with obesity undergoing bariatric surgery. Methods: This is a prospective randomized clinical study, that was carried out with individuals of both sexes, ≥65 years, undergoing GB or SG and who met the inclusion criteria. Age, gender and comorbidities (type 2 diabetes mellitus, arterial hypertension, dyslipidemia and osteoarthrosis) were collected and analyzed at baseline. Anthropometric data (weight, body mass index, percentage of weight loss, percentage of excess weight loss), laboratory tests related to bone health and bone mineral density were analyzed before and 24 months after surgery. Results: A total of 36 patients (GB, n=18; SG, n=18) were evaluated. At baseline, except for sex and preoperative body mass index, which was higher in GB, groups were similar. After 24 months, GB was superior for weight loss (%WL) and excess weight loss (%EWL). Regarding bone health, a significant decrease of BMD was observed in the spine, total proximal femur and femoral neck in all groups, with an average decrease of 5.1%, 10.5% and 15.1%, respectively. In addition, the observed decrease in BMD was up to 25% in the total femur after 24 months, six patients went from normal BMD to osteopenia and one from osteopenia to osteoporosis. There was no difference in parathormone values. However, there was an association between the increase in parathormone and the decrease in BMD in the spine, mainly in the GB group. There was no association between %WL and %EWL with the reduction in BMD. Conclusion: Bariatric surgery was related to the reduction of BMD in elderly patients, but there was no statistical difference between the two surgical techniques.

RESUMO Contexto: A cirurgia bariátrica promove mudanças na composição corporal, que incluem a perda de densidade mineral óssea (DMO). Faltam estudos que avaliem a evolução da saúde óssea de idosos que foram submetidos a cirurgia bariátrica, e sobre eventuais diferenças nessa evolução, quando comparadas as técnicas Bypass gástrico (BP) e gastrectomia vertical (GV). Objetivo: Avaliar a saúde óssea de pacientes idosos com obesidade submetidos a cirurgia bariátrica. Métodos: Trata-se de estudo prospectivo randomizado, realizado com indivíduos de ambos os sexos, ≥65 anos, submetidos a BP ou GV e que atendiam os critérios de inclusão. Idade, sexo e comorbidades (diabetes mellitus tipo 2, hipertensão arterial, dislipidemia e osteoartrose) foram coletados no momento da cirurgia bariátrica. Dados antropométricos (peso, índice de massa corporal, percentual de perda de peso, percentual de excesso de peso), exames laboratoriais relacionados a saúde óssea e densitometria óssea foram realizados antes e com 24 meses de pós-operatório. A evolução das variáveis estudadas foi feita comparando o pré e pós-operatório da casuística como um todo e dos grupos separadamente e entre si. Resultados: Um total de 36 pacientes (BP, n=18; GV, n=18) foram avaliados. As características basais da amostra, exceto pelo sexo e índice de massa corporal, que era maior no BP, foram homogêneas. Após 24 meses, o BP foi superior para perda de peso (%PP) e perda de excesso de peso (%PEP). Quanto à saúde óssea, observou-se uma diminuição significante da DMO na coluna, fêmur proximal total e colo do fêmur em ambos os grupos, com uma média de queda de 5,1%, 10,5% e 15,1%, respectivamente. Além disso, a queda da DMO observada foi de até 25% no fêmur total após 24 meses, seis pacientes passaram de DMO normal para osteopenia e um de osteopenia para osteoporose. Não houve diferença nos valores de paratormônio. Entretanto, houve associação entre o aumento do paratormônio e a redução da DMO na coluna, particularmente no grupo BP. Não foi observado associação entre %PP e %PEP com a redução da DMO. Conclusão: A cirurgia bariátrica se relacionou com a redução da DMO, porém sem diferença estatística entre as duas técnicas cirúrgicas.

Gastrointestinal and sensory manifestations, nutrition management, and energy-protein intake in hospitalized patients with COVID-19.

BACKGROUND: Gastrointestinal and sensory manifestations (GSMs) of coronavirus disease 2019 (COVID-19) may affect food intake, resulting in malnutrition and poor outcomes. We characterized the impact of GSMs and oral nutrition supplementation on energy-protein intake (EPI) and hospital discharge in adult patients with COVID-19. METHODS: Patients from two hospitals were enrolled (n = 357). We recorded the presence and type of GSM at admission, estimated energy requirements (EER) and the EPI based on regular food intake (plate diagram sheets) during hospital stays. Patients not achieving 60% of their EER from food over 2 consecutive days received oral nutrition supplementation (ONS) with a high-energy-protein oral drink. RESULTS: Most patients (63.6%) presented with GSMs at admission. Anorexia was the most common manifestation (44%). Patients with anorexia or more than one GSMs were more likely to not achieve 60% EER on the first day of follow-up and to require the ONS intervention (P ≤ 0.050). Prevalence of at least one GSM was higher in patients who did not achieve hospital discharge than in patients who achieved it (74.2% vs 54.6%, P = 0.038). The patients requiring ONS (26.9%) demonstrated good adherence to the intervention (79.3%), achieved their EER during 95.7% of the supplementation time, and presented with hospital discharge rates similar to patients not requiring ONS (92.2% vs 91.9%, respectively; P = 1.000). CONCLUSIONS: GSM were prevalent in COVID-19 and it impaired EER attendance and patient recovery. ONS was well-tolerated, aided EER attendance, and potentially facilitated hospital discharge.

FOOD TOLERANCE AND NUTRITIONAL RISK AFTER SLEEVE GASTRECTOMY AND ROUX-EN-Y GASTRIC BYPASS IN ELDERLY PATIENTS WITH SEVERE OBESITY: A PROSPECTIVE, RANDOMIZED CONTROLLED TRIAL.

BACKGROUND: Bariatric surgery is still controversial in elderly patients with severe obesity. Most publications focus on safety and early clinical outcomes. Food tolerance and nutritional postoperative risk is unknown for this population. METHODS: Thirty-six elderly patients with severe obesity were recruited for an open-label randomized trial from September 2017 to May 2019 comparing laparoscopic sleeve gastrectomy (LSG) to Roux-en-Y Gastric Bypass (LRYGB). Food tolerance was accessed by Quality of Alimentation (QoA) questionnaire and data on weight loss, body composition, and nutritional risk were collected between 6 and 24 months after surgery. RESULTS: Comparing LSG to LRYGB patients, the latter had higher total weight loss (22% vs 31%, P=0.01) and excess weight loss (53% vs 68%, P=0.01). Food tolerance to eight food groups was similar between groups (14 vs 15 points, P=0.270), as Suter score (23 vs 25, P=0.238). Daily protein intake was below recommendation in both groups (40 vs 51 g/d, P=0.105). Nutritional risk, evaluated through Standardized Phase Angle (-1.48 vs -1.99, P=0.027), was worse for LRYGB group. CONCLUSION: Food tolerance and adequacy of food consumption were similar in both groups. LRYGB patients had higher nutritional risk.

Tolerância alimentar e risco nutricional após gastrectomia vertical e bypass gástrico em Y-de-Roux em pacientes idosos com obesidade grave: um estudo clínico prospectivo randomizado / Food tolerance and nutritional risk after sleeve gastrectomy and roux-en-y gastric bypass in elderly patients with severe obesity: a prospective, randomized controlled trial

ABSTRACT Background: Bariatric surgery is still controversial in elderly patients with severe obesity. Most publications focus on safety and early clinical outcomes. Food tolerance and nutritional postoperative risk is unknown for this population. Methods: Thirty-six elderly patients with severe obesity were recruited for an open-label randomized trial from September 2017 to May 2019 comparing laparoscopic sleeve gastrectomy (LSG) to Roux-en-Y Gastric Bypass (LRYGB). Food tolerance was accessed by Quality of Alimentation (QoA) questionnaire and data on weight loss, body composition, and nutritional risk were collected between 6 and 24 months after surgery. Results: Comparing LSG to LRYGB patients, the latter had higher total weight loss (22% vs 31%, P=0.01) and excess weight loss (53% vs 68%, P=0.01). Food tolerance to eight food groups was similar between groups (14 vs 15 points, P=0.270), as Suter score (23 vs 25, P=0.238). Daily protein intake was below recommendation in both groups (40 vs 51 g/d, P=0.105). Nutritional risk, evaluated through Standardized Phase Angle (-1.48 vs -1.99, P=0.027), was worse for LRYGB group. Conclusion: Food tolerance and adequacy of food consumption were similar in both groups. LRYGB patients had higher nutritional risk.

RESUMO Contexto: A cirurgia bariátrica ainda é controversa em pacientes idosos com obesidade grave. A maioria das publicações tem foco em segurança e desfechos clínicos precoces. A tolerância alimentar e o risco nutricional pós-operatório são desconhecidos para essa população. Métodos: Trinta e seis pacientes idosos com obesidade grave foram recrutados para um estudo clínico randomizado de setembro de 2017 a maio de 2019 comparando gastrectomia vertical com Bypass Gástrico em Y-de-Roux (BGYR). A tolerância alimentar foi avaliada pelo questionário de qualidade alimentar e dados sobre perda de peso, composição corporal e risco nutricional foram coletados entre 6 e 24 meses após a cirurgia. Resultados: Comparando os pacientes de gastrectomia vertical com BGYR, estes tiveram maior perda de peso total (22% vs 31%, P=0,01) e perda do excesso de peso (53% vs 68%, P=0,01). A tolerância alimentar para oito grupos foi similar entre grupos 14 vs 15 pontos, P=0,270), bem como o escore de Suter (23 vs 25, P=0,238). A ingestão diária de proteínas foi abaixo do recomendado para ambos os grupos (40 vs 51 g/d, P=0,105). O risco nutricional, avaliado através do ângulo de fase padronizado (-1,48 vs -1,99, P=0,027), foi pior para o grupo do BGYR. Conclusão: A tolerância alimentar e adequação do consumo alimentar foi similar entre os grupos. Pacientes submetidos a BGYR tiveram maior risco nutricional.

Weight loss among pregnant women hospitalized because of hyperemesis gravidarum: Is there a lack of nutrition intervention?

BACKGROUND: Nutrition therapy is a key component in the management of hyperemesis gravidarum (HG). The aim of this study was to describe sociodemographic, anthropometric, and nutrition aspects of pregnant women hospitalized because of HG and raise a discussion about the nutrition care provided. MATERIALS AND METHODS: This is a retrospective descriptive study that includes 26 pregnant women with confirmed diagnosis of HG who were hospitalized because of this condition in a tertiary hospital. Data of interest were collected from official medical records and analyzed to obtain measures of central tendency and dispersion, as well as frequencies. RESULTS: The studied individuals had a mean age of 25.7 years and a low level of education, and 65% of them were single mothers. They registered a low weight gain (2.8 kg) during pregnancy and in the course of their hospitalization, during which they lost an average of 1.7 kg, showing a decline in nutrition status during this period. Although the average intake of oral diet (OD) was 55% during hospital stay and only 5% of the studied population met caloric needs through OD, the prescription of complementary medical nutrition therapy (oral supplements, enteral or parenteral nutrition) was scarcely observed in this sample. CONCLUSION: Despite the negative impact that HG can impose on the mother's nutrition status and the known benefits that complementary nutrition therapies can provide, few nutrition interventions have been carried out to improve this situation. That indicates an urgent need for implementation or reviewing of nutrition assistance protocols for HG patients.

Hospital and homecare malnutrition and nutritional therapy in Brazil. Strategies for alleviating it: a position paper.

INTRODUCTION: Malnutrition in hospitalized patients is not evaluated frequently. However, it is a critical issue given that it has been related to a high rate of infectious complications and increased mortality rates. There is a high prevalence of patients with nutritional impairment in the home environment, which favors their clinical worsening, the increase of re-hospitalizations and, consequently, the increase in public health expenditures. OBJECTIVE: Nutrition experts have thoroughly discussed and written this positioning paper on hospital and homecare malnutrition to describe the prevalence of malnutrition in Brazil. Best practice recommendations for nutrition therapy of patients in hospital and homecare, in particular the use of oral nutritional supplements (ONS), to those who are at risk of malnutrition or malnourished were evaluated, and the impact on clinical and economic data were assessed. In addition, they emphasize that investments in oral nutritional supplementation are also important in the homecare environment (home or nursing homes). MATERIALS AND METHODS: Selected scientific articles on disease-related malnutrition, especially those carried out in Brazil, were assessed. Data on prevalence, clinical outcomes, and economic burdens were reviewed. RESULTS AND CONCLUSION: Several studies have shown the importance of in-hospital nutritional assessment for early detection of malnutrition and early intervention with nutrition therapy, in particular with oral nutritional therapy. Unfortunately, hospital malnutrition remains high in Brazil, with severe consequences for patients. The implementation of universal nutritional screening and diagnosis as well as the therapeutic approach of malnutrition, particularly with the use, when possible, of oral nutrition supplements as the first step to address this condition is still low, and demands the investment in educational resources to change practices. Routine use of nutritional therapy in hospital and homecare settings improves clinical outcomes, is cost effective, and would be expected to help reduce healthcare costs.

Inquérito brasileiro sobre o estado atual da terapia nutricional domiciliar / Brazilian survey on the current state of home nutritional therapy

Introdução: A nutrição adequada é essencial para qualidade de vida e para a saúde, por reduzir morbimortalidade, dias de hospitalização e os custos totais com saúde. A terapia nutricional (TN) tem como objetivo manter ou recuperar o estado nutricional/funcional dos pacientes e tem crescido sua indicação no cuidado domiciliar (CD). Apesar do crescimento da TN no domicílio, poucos dados existem na literatura. Desta forma, o Comitê de Assistência Nutricional Domiciliar (CAND) da SBNPE/BRASPEN realizou um questionário para avaliar a situação brasileira da assistência nutricional domiciliar (AND). Método: Realizado um questionário por meio da ferramenta Survey Monkey www.surveymonkey.com enviado via mala direta a todos associados da BRASPEN, à coordenação do programa Melhor em Casa e ao Núcleo Nacional das Empresas de Serviços de Atenção Domiciliar (NEAD Saúde), no período de julho de 2016 a janeiro de 2017. Resultados: Retornaram 560 respostas, 89% relativos à saúde suplementar. O nutricionista foi responsável por 74% das respostas e a maior região contribuinte foi o Sudeste (48%) seguido pelo Nordeste (20%). Indivíduos de 60 anos ou mais e com doenças neurológicas correspondem à maioria dos atendimentos domiciliares em TN. A nutrição enteral domiciliar (TNED) é a mais utilizada (84%), com uso de dieta industrializada/mista com indicação semelhante entre setor público e privado. A via de acesso mais utilizada é sonda nasogástrica/nasoentérica em 59%. A orientação recebida pelos pacientes e familiares para TN é dada na hora da alta hospitalar em 32% dos casos. Conclusão: São poucas as informações existentes na literatura de dados brasileiros sobre terapia nutricional domiciliar (TND). Este inquérito reflete o estado atual desta prática em nosso país e justifica a importância em delinear uma normatização mais firme para a prática de TND.(AU)

Introduction: Adequate nutrition is essential for quality of life and for health by reducing morbidity and mortality, hospitalization days and total health costs. Nutritional therapy (NT) aims to maintain or restore the nutritional status of patients and has increased its indication in home care. Despite the growth of NT at home, few data exist in the literature, so the home nutritional assistance committee from the Brazilian society of enteral and parenteral nutrition (SBNPE / BRASPEN) conducted a questionnaire to evaluate the Brazilian situation of home nutritional assistance (HNA). Method: A questionnaire was carried out using the Survey Monkey tool (www.surveymonkey.com) and sent by mail to all members of SBNPE / BRASPEN, the coordination of the Home public program and the National Center for Home Care Services Companies (NEAD Saúde) in the period from July 2016 to January 2017. Results: 560 responses returned, 89% related from private health. The nutritionist was responsible for 74% of the responses and the largest contributing region was the Southeast (48%) followed by the Northeast (20%) from Brazil. Individuals aged 60 years or older and with neurological diseases correspond to the majority of home patients in NT. Home enteral nutrition (HEN) is the most used (84%) with the use of industrialized / mixed diet with similar indication between public and private health sector. The most commonly used route of access is nasoenteral / nasogastric probe in 59%. The orientation received by patients and relatives for TN is given at the time of hospital discharge in 32% of cases. Conclusion: There is a little information in the Brazilian data literature on home nutritional therapy (HNT). This survey reflects the current state of this practice in our country and justifies the importance in outlining a firmer standardization for the practice of HNT.(AU)

Hospital and homecare malnutrition and nutritional therapy in Brazil. Strategies for alleviating it: a position paper / Desnutrición y terapia nutricional en hospitales y en domicilios en Brasil. Estrategias para aliviarlo: posicionamiento

Introduction: Malnutrition in hospitalized patients is not evaluated frequently. However, it is a critical issue given that it has been related to a high rate of infectious complications and increased mortality rates. There is a high prevalence of patients with nutritional impairment in the home environment, which favors their clinical worsening, the increase of re-hospitalizations and, consequently, the increase in public health expenditures. Objective: Nutrition experts have thoroughly discussed and written this positioning paper on hospital and homecare malnutrition to describe the prevalence of malnutrition in Brazil. Best practice recommendations for nutrition therapy of patients in hospital and homecare, in particular the use of oral nutritional supplements (ONS), to those who are at risk of malnutrition or malnourished were evaluated, and the impact on clinical and economic data were assessed. In addition, they emphasize that investments in oral nutritional supplementation are also important in the homecare environment (home or nursing homes). Materials and methods: Selected scientific articles on disease-related malnutrition, especially those carried out in Brazil, were assessed. Data on prevalence, clinical outcomes, and economic burdens were reviewed. Results and conclusion: Several studies have shown the importance of in-hospital nutritional assessment for early detection of malnutrition and early intervention with nutrition therapy, in particular with oral nutritional therapy. Unfortunately, hospital malnutrition remains high in Brazil, with severe consequences for patients. The implementation of universal nutritional screening and diagnosis as well as the therapeutic approach of malnutrition, particularly with the use, when possible, of oral nutrition supplements as the first step to address this condition is still low, and demands the investment in educational resources to change practices. Routine use of nutritional therapy in hospital and homecare settings improves clinical outcomes, is cost effective, and would be expected to help reduce healthcare costs (AU)

Introducción: la desnutrición en pacientes hospitalizados no se evalúa con frecuencia. Sin embargo, es un problema crítico dado que se ha relacionado con una alta tasa de complicaciones infecciosas y con el incremento de la mortalidad. Se observa una alta prevalencia de pacientes desnutridos en el entorno domiciliario, lo que favorece su deterioro clínico, el aumento de las rehospitalizaciones y, como consecuencia, el aumento del gasto sanitario público. Objetivo: expertos en nutrición realizaron una revisión detallada de los estudios para redactar un posicionamiento sobre la situación en Brasil respecto a la prevalencia de la desnutrición hospitalaria y domiciliaria. Se identificaron las mejores prácticas recomendadas para la terapia nutricional de los pacientes hospitalarios y en domicilio en riesgo de desnutrición o desnutridos y se evaluó la utilidad de los suplementos nutricionales orales (SNO) a través de datos clínicos y económicos. Adicionalmente, se evidenció que las inversiones en suplementos nutricionales orales son también importantes en el entorno domiciliario (domicilio o residencia). Materiales y métodos: se evaluaron artículos científicos seleccionados, especialmente los realizados en Brasil, sobre la desnutrición relacionada con enfermedades. Se revisaron los datos sobre la prevalencia, los resultados clínicos y las cargas económicas. Resultados y conclusión: varios estudios han demostrado la importancia de la evaluación nutricional en el hospital para la detección precoz de la desnutrición y la intervención temprana con terapia nutricional oral, siempre que sea posible, como estrategia inicial para abordar el problema. Desafortunadamente, la desnutrición hospitalaria continúa siendo elevada en Brasil, con consecuencias graves para los pacientes. La identificación del estado nutricional deficiente a través del cribado y el inicio de la terapia nutricional, particularmente con el uso, cuando es posible, de suplementos nutricionales orales, como primera etapa para combatir la desnutrición no está aún establecida y requiere una inversión en recursos educativos para cambiar las prácticas actuales. El uso rutinario de la terapia nutricional en el entorno hospitalario y domiciliario mejora los resultados clínicos y tiene un impacto positivo en la disminución de los costes asociados y, de esta forma, se espera que contribuya a la reducción de los costes de atención sanitaria (AU)

Maternal obesity in high-risk pregnancies and postpartum infectious complications.

OBJECTIVE: To analyze the association between maternal obesity and postnatal infectious complications in high-risk pregnancies. METHODS: Prospective study from August 2009 through August 2010 with the following inclusion criteria: women up to the 5(th) postpartum day; age ≥ 18 years; high-risk pregnancy; singleton pregnancy with live fetus at labor onset; delivery at the institution; maternal weight measured on day of delivery. The nutritional status in late pregnancy was assessed by the body mass index (BMI), with the application of the Atalah et al. curve. Patients were graded as underweight, adequate weight, overweight, or obese. Postpartum complications investigated during the hospital stay and 30 days post-discharge were: surgical wound infection and/or secretion, urinary infection, postpartum infection, fever, hospitalization, antibiotic use, and composite morbidity (at least one of the complications mentioned). RESULTS: 374 puerperal women were included, graded according to the final BMI as: underweight (n = 54, 14.4%); adequate weight (n = 126, 33.7%); overweight (n = 105, 28.1%); and obese (n = 89, 23.8%). Maternal obesity was shown to have a significant association with the following postpartum complications: surgical wound infection (16.7%, p = 0.042), urinary infection (9.0%, p = 0.004), antibiotic use (12.3%, p < 0.001), and composite morbidity (25.6%, p = 0.016). By applying the logistic regression model, obesity in late pregnancy was found to be an independent variable regardless of the composite morbidity predicted (OR: 2.09; 95% CI: 1.15-3.80, p = 0.015). CONCLUSION: Maternal obesity during late pregnancy in high-risk patients is independently associated with postpartum infectious complications, which demonstrates the need for a closer follow-up of maternal weight gain in these pregnancies.

Obesidade materna em gestações de alto risco e complicações infecciosas no puerpério / Maternal obesity in high-risk pregnancies and postpartum infectious complications

OBJETIVO: Analisar a associação entre a obesidade materna e complicações infecciosas do puerpério em gestações de alto risco. MÉTODOS: Estudo prospectivo de ago/2009 a ago/2010, com os seguintes critérios de inclusão: puérperas até o 5º dia; idade >18 anos; gestação de alto risco; feto único e vivo no início do trabalho de parto; parto na instituição; peso materno aferido no dia do parto. O estado nutricional no final da gestação foi avaliado pelo índice de massa corporal (IMC), aplicando-se a curva de Atalah et al. (1997), e as pacientes foram classificadas em: baixo peso, adequado, sobrepeso e obesidade. As complicações do puerpério, investigadas durante o período de internação e 30 dias após a alta, foram: infecção e/ou secreção em ferida cirúrgica, infecção urinária, infecção puerperal, febre, hospitalização, uso de antibióticos e morbidade composta (pelo menos uma das complicações citadas). RESULTADOS: Foram incluídas 374 puérperas classificadas pelo IMC final em: baixo peso (n = 54, 14,4%); adequado (n = 126, 33,7%); sobrepeso (n = 105, 28,1%) e obesidade (n = 89, 23,8%). A obesidade materna apresentou associação significativa com as seguintes complicações do puerpério: infecção de ferida cirúrgica (16,7%, p = 0,042), infecção urinária (9,0%, p = 0,004), uso de antibiótico (12,3%, p < 0,001) e morbidade composta (25,6%, p = 0,016). Aplicando-se o modelo de regressão logística verificouse que a obesidade no final da gestação é variável independente na predição da morbidade composta (OR: 2,09; IC 95%: 1,15-3,80, p = 0,015). CONCLUSÃO: A obesidade materna no final da gravidez, em pacientes de alto risco, está associada de forma independente à ocorrência de complicações infecciosas no puerpério, demonstrando a necessidade de acompanhamento mais eficiente de ganho de peso materno nessas gestações.

OBJECTIVE: To analyze the association between maternal obesity and postnatal infectious complications in high-risk pregnancies. METHODS: Prospective study from August 2009 through August 2010 with the following inclusion criteria: women up to the 5th postpartum day; age > 18 years; high-risk pregnancy; singleton pregnancy with live fetus at labor onset; delivery at the institution; maternal weight measured on day of delivery. The nutritional status in late pregnancy was assessed by the body mass index (BMI), with the application of the Atalah et al. curve. Patients were graded as underweight, adequate weight, overweight, or obese. Postpartum complications investigated during the hospital stay and 30 days post-discharge were: surgical wound infection and/or secretion, urinary infection, postpartum infection, fever, hospitalization, antibiotic use, and composite morbidity (at least one of the complications mentioned). RESULTS: 374 puerperal women were included, graded according to the final BMI as: underweight (n = 54, 14.4%); adequate weight (n = 126, 33.7%); overweight (n = 105, 28.1%); and obese (n = 89, 23.8%). Maternal obesity was shown to have a significant association with the following postpartum complications: surgical wound infection (16.7%, p = 0.042), urinary infection (9.0%, p = 0.004), antibiotic use (12.3%, p < 0.001), and composite morbidity (25.6%, p = 0.016). By applying the logistic regression model, obesity in late pregnancy was found to be an independent variable regardless of the composite morbidity predicted (OR: 2.09; 95% CI: 1.15-3.80, p = 0.015). CONCLUSION: Maternal obesity during late pregnancy in high-risk patients is independently associated with postpartum infectious complications, which demonstrates the need for a closer follow-up of maternal weight gain in these pregnancies.

Bioelectrical impedance analysis and skinfold thickness sum in assessing body fat mass of renal dialysis patients.

OBJECTIVE: In chronic renal failure patients under hemodialysis (HD) treatment, the availability of simple, safe, and effective tools to assess body composition enables evaluation of body composition accurately, in spite of changes in body fluids that occur in dialysis therapy, thus contributing to planning and monitoring of nutritional treatment. We evaluated the performance of bioelectrical impedance analysis (BIA) and the skinfold thickness sum (SKF) to assess fat mass (FM) in chronic renal failure patients before (BHD) and after (AHD) HD, using air displacement plethysmography (ADP) as the standard method. DESIGN: This single-center cross-sectional trial involved comparing the FM of 60 HD patients estimated BHD and AHD by BIA (multifrequential; 29 women, 31 men) and by SKF with those estimated by the reference method, ADP. Body fat-free mass (FFM) was also obtained by subtracting the total body fat from the individual total weight. RESULTS: Mean estimated FM (kg [%]) observed by ADP BHD was 17.95 ± 0.99 kg (30.11% ± 1.30%), with a 95% confidence interval (CI) of 16.00 to 19.90 (27.56 to 32.66); mean estimated FM observed AHD was 17.92 ± 1.11 kg (30.04% ± 1.40%), with a 95% CI of 15.74 to 20.10 (27.28 to 32.79). Neither study period showed a difference in FM and FFM (for both kg and %) estimates by the SKF method when compared with ADP; however, the BIA underestimated the FM and overestimated the FFM (for both kg and %) when compared with ADP. CONCLUSION: The SKF, but not the BIA, method showed results similar to ADP and can be considered adequate for FM evaluation in HD patients.

[Dietary intake of pregnant women and maternal weight gain after nutritional counseling]. / Consumo dietético de gestantes e ganho ponderal materno após aconselhamento nutricional.

PURPOSE: to determine the dietary consumption of pregnant women, by assessing the intake of macronutrients and micronutrients, and to verify the maternal weight gain during pregnancy. METHODS: a retrospective study conducted from June 2002 to June 2008 with pregnant women who received nutritional counseling during prenatal care at a university hospital, grouped according to anthropometric nutritional status classified by pregestational body mass index (BMI). The dietary intake was analyzed according to the information obtained in food frequency interviews, performed at the first evaluation of pregnant women in the service of nutrition to obtain data about eating habits, and the intake of macronutrients and micronutrients was calculated. The pregnant women received nutritional counseling, and the maternal weight gain was investigated. RESULTS: a total of 187 pregnant women who received nutritional counseling were analyzed. Twenty-three (12.2%) were underweight, 84 (45.0%) normal weight, 37 (19.8%) overweight, and 43 (23.0%) obese. The underweight pregnant women had lower consumption of lipids when compared to the normal weight group (101.4 versus 137.3 g; p=0.043). The average iron intake was higher in normal weight pregnant women (14.6 mg/d) compared to the overweight (12.2 mg/d) or obese (10.9 mg/d; p<0.001) groups. The average intake of folate was higher in normal weight pregnant women compared to obese ones (336.5 µg/d versus 234.5 µg/d; p=0.002). Excessive maternal weight gain was significantly (p=0.009) more frequent in overweight (56.7%) and obese (39.5%) pregnant women compared to underweight (17.4%) and normal weight (31.0%) women. CONCLUSIONS: The maternal weight gain above recommended levels was associated with overweight and obesity. The dietary intake of pregnant women differs according to maternal anthropometric nutritional status, with a lower daily intake of iron in overweight and obese women and a lower intake of folate in obese ones, a fact that reinforces the importance of prenatal vitamin supplementation.

Constipação intestinal e gravidez / Constipation in pregnancy

A constipação intestinal é queixa frequente no atendimento obstétrico, e está associada a dificuldades na defecação, seja pelo emprego de força e/ou diminuição de frequência na evacuação. Na gravidez, além dos fatores relacionados à dieta, como a baixa ingestão de fibras e água, outros contribuem para a piora deste sintoma, tais como: suplementação de ferro, redução na atividade física, motilidade reduzida do cólon e os efeitos hormonais sobre a motilidade gastrintestinal. Apesar de a anamnese detalhada permitir a identificação da constipação, alguns critérios específicos são propostos para auxiliar o reconhecimento deste sintoma. Entender a constipação no período gestacional é importante, pois é condição comum que leva a queixas nas consultas médicas resultando em altos custos para a saúde pública. O maior conhecimento dos fatores associados a este sintoma pode auxiliar no tratamento e delineamento de estratégias de conduta, visando melhorar a qualidade de vida das gestantes afetadas pela constipação.

Constipation is a frequent complaint in obstetric care, and is associated with difficulties in defecation, either by using force and/or decreased frequency in the evacuation. In pregnancy, in addition to dietary factors, such as low intake of fiber and water, iron supplementation, reduction in physical activity, reduced colonic motility and the hormonal effects on gastrintestinal motility also contribute to the worsening of this symptom. Although the detailed history of constipation can be identified, some specific criteria are proposed to assist the recognition of this symptom. Understanding constipation during pregnancy is important because it is a common condition that leads to complaints in medical consultations resulting in high costs to public health. Knowledge of the factors associated with this symptom may help to establish treatments and to manage strategies to improve the quality of life of pregnant women affected by constipation.

Anemia during pregnancy after silastic ring Roux-en-Y gastric bypass: influence of time to conception.

BACKGROUND: Bariatric surgery before pregnancy may help prevent obesity-related gestational complications. However, maternal malnutrition is not without potential risks during pregnancy. The objective was to evaluate the influence of time to conception after silastic ring Roux-en-Y gastric bypass (SRYGB) on maternal anemia. METHODS: Patients who underwent SRYGB for morbid obesity and who subsequently became pregnant were followed up at the prenatal. Thirty pregnancies occurred between July 2001 and September 2009. The patients were analyzed according to time to conception after bariatric surgery: 17 patients with time to conception <4 years (48 months) and 13 patients with ≥ 4 years. RESULTS: First trimester hemoglobin levels were significantly lower in patients with time to conception ≥ 4 years (48 months) (median 9.6 g/dL, range 5.8-13.2 g/dL) than in patients with time to conception <4 years (median 11.1 g/dL, range 9.8-13.6 g/dL; p=0.047). The need for intravenous iron therapy or packed red cell transfusion was significantly more frequent among women who became pregnant ≥ 4 years after SRYGB compared to <4 years (30.8% vs. 0%, p=0.026). CONCLUSION: Pregnancy after 4 years of SRYGB is associated with maternal anemia and the need for more strict iron supplementation.

Consumo dietético de gestantes e ganho ponderal materno após aconselhamento nutricional / Dietary intake of pregnant women and maternal weight gain after nutritional counseling

OBJETIVOS: conhecer o consumo dietético de gestantes avaliando a ingestão de macronutrientes e micronutrientes, e verificar o ganho ponderal materno na gravidez. MÉTODOS: estudo retrospectivo do período de junho de 2002 a junho de 2008 com gestantes que receberam orientação nutricional durante pré-natal em hospital universitário, agrupadas de acordo com o estado nutricional antropométrico classificado pelo índice de massa corpórea (IMC) pré-gestacional. O consumo dietético foi analisado pelas informações de entrevista de frequência alimentar realizada na primeira avaliação da gestante no serviço de nutrição, para obter os dados do hábito alimentar, calculando-se a ingestão de macronutrientes e micronutrientes. As gestantes receberam aconselhamento nutricional, e foi analisado o ganho ponderal materno na gravidez. RESULTADOS: do total de 187 gestantes que receberam orientação nutricional, 23 (12,2 por cento) eram de baixo peso, 84 (45,0 por cento), eutróficas, 37 (19,8 por cento) com sobrepeso, e 43 (23,0 por cento), obesas. As gestantes de baixo peso apresentaram menor consumo de lípides quando comparadas ao grupo com eutrofia (101,4 versus 137,3 g; p=0,043). A média do consumo de ferro foi maior nas gestantes eutróficas (14,6 mg/d) quando comparadas às com sobrepeso (12,2 mg/d) ou obesidade (10,9 mg/d; p<0,001). A média da ingestão de folatos foi maior nas gestantes eutróficas quando comparadas às obesas (336,5 versus 234,5 µg/d; p=0,002). O ganho de peso excessivo, acima do recomendado, foi significativamente mais frequente (p=0,009) nas gestantes com sobrepeso (56,7 por cento) e obesidade (39,5 por cento) quando comparadas às com baixo peso (17,4 por cento) e eutrofia (31,0 por cento)...

PURPOSE: to determine the dietary consumption of pregnant women, by assessing the intake of macronutrients and micronutrients, and to verify the maternal weight gain during pregnancy. METHODS: a retrospective study conducted from June 2002 to June 2008 with pregnant women who received nutritional counseling during prenatal care at a university hospital, grouped according to anthropometric nutritional status classified by pregestational body mass index (BMI). The dietary intake was analyzed according to the information obtained in food frequency interviews, performed at the first evaluation of pregnant women in the service of nutrition to obtain data about eating habits, and the intake of macronutrients and micronutrients was calculated. The pregnant women received nutritional counseling, and the maternal weight gain was investigated. RESULTS: a total of 187 pregnant women who received nutritional counseling were analyzed. Twenty-three (12.2 percent) were underweight, 84 (45.0 percent) normal weight, 37 (19.8 percent) overweight, and 43 (23.0 percent) obese. The underweight pregnant women had lower consumption of lipids when compared to the normal weight group (101.4 versus 137.3 g; p=0.043). The average iron intake was higher in normal weight pregnant women (14.6 mg/d) compared to the overweight (12.2 mg/d) or obese (10.9 mg/d; p<0.001) groups. The average intake of folate was higher in normal weight pregnant women compared to obese ones (336.5 µg/d versus 234.5 µg/d; p=0.002). Excessive maternal weight gain was significantly (p=0.009) more frequent in overweight (56.7 percent) and obese (39.5 percent) pregnant women compared to underweight (17.4 percent) and normal weight (31.0 percent) women...

Comparison of nutritional risk screening tools for predicting clinical outcomes in hospitalized patients.

OBJECTIVE: International nutritional screening tools are recommended for screening hospitalized patients for nutritional risk, but no tool has been specifically evaluated in the Brazilian population. The aim of this study was to identify the most appropriate nutritional screening tool for predicting unfavorable clinical outcomes in patients admitted to a Brazilian public university hospital. METHODS: The Nutritional Risk Screening 2002 (NRS 2002), Mini-Nutritional Assessment-Short Form (MNA-SF), and Malnutrition Universal Screening Tool (MUST) were administered to 705 patients within 48 h of hospital admission. Tool performance in predicting complications, very long length of hospital stay (LOS), and death was analyzed using receiver operating characteristic curves. RESULTS: NRS 2002, MUST, and MNA-SF identified nutritional risk in 27.9%, 39.6%, and 73.2% of the patients, respectively. NRS 2002 (complications: 0.6531; very long LOS: 0.6508; death: 0.7948) and MNA-SF (complications: 0.6495; very long LOS: 0.6197; death: 0.7583) had largest areas under the ROC curve compared to MUST (complications: 0.6036; very long LOS: 0.6109; death: 0.6363). For elderly patients, NRS 2002 was not significantly different than MNA-SF (P>0.05) for predicting outcomes. CONCLUSION: Considering current criteria for nutritional risk, NRS 2002 and MNA-SF have similar performance to predict outcomes but NRS 2002 seems to provide a best yield.

[Assessment of fetal vitality and perinatal results in pregnancies after gastroplasty with Roux-en-Y gastric bypass]. / Avaliação da vitalidade fetal e resultados perinatais em gestações após gastroplastia com derivação em Y de Roux.

OBJECTIVE: To study fetal vitality assessed in pregnancies after gastroplasty with Roux-en-Y gastric bypass and verify maternal complications and perinatal results. METHODS: Hospital charts of all pregnancies after gastroplasty with Roux-en-Y gastric bypass were reviewed retrospectively. All cases followed at the specialized prenatal care that gave birth in this institution, between July 2001 and September 2009, were reviewed. The assessment of fetal vitality (cardiotocography, fetal biophysical profile and umbilical artery Doppler velocimetry) performed in the last week before delivery were analyzed. The maternal variables investigated were: demographic data, maternal complications, mode of delivery, complications during delivery and postpartum, maternal blood exams and perinatal results. RESULTS: During the study period 30 pregnancies after gastroplasty with Roux-en-Y gastric bypass were identified and 24 of them had undergone assessment of fetal vitality. All patients presented normal cardiotocography, normal fetal biophysical profile and normal results at the umbilical artery Doppler velocimetry. One case presented with oligohydramnios. The main complication observed was maternal anemia (Hb < 11.0 g/dL, 86.7%). Cesarean section was performed in 21 pregnancies (70%). Delivery complications included one case of adherences, one hematoma and infection of abdominal wall scar and one postpartum hysterectomy for myoma and uterine atony. The proportion of small infants for gestational age was 23.3%. CONCLUSION: Fetal vitality was not compromised in pregnancies after gastroplasty with Roux-en-Y gastric bypass. The main maternal complication was anemia, therefore these women require specific nutritional counseling and a broad evaluation for micronutrient deficiencies at early pregnancy.