Assessment of adult malnutrition and prognosis with bioelectrical impedance analysis: phase angle and impedance ratio.

PURPOSE OF REVIEW: Malnutrition affects prognosis in many groups of patients. Although screening tools are available to identify adults at risk for poor nutritional status, a need exists to improve the assessment of malnutrition by identifying the loss of functional tissues that can lead to frailty, compromised physical function, and increased risk of morbidity and mortality, particularly among hospitalized and ill patients and older adults. Bioimpedance analysis (BIA) offers a practical approach to identify malnutrition and prognosis by assessing whole-body cell membrane quality and depicting fluid distribution for an individual. RECENT FINDINGS: Two novel applications of BIA afford opportunities to safely, rapidly, and noninvasively assess nutritional status and prognosis. One method utilizes single-frequency phase-sensitive measurements to determine phase angle, evaluate nutritional status, and relate it to prognosis, mortality, and functional outcomes. Another approach uses the ratio of multifrequency impedance values to indicate altered fluid distribution and predict prognosis. SUMMARY: Use of basic BIA measurements, independent of use of regression prediction models and assumptions of constant chemical composition of the fat-free body, enables new options for practical assessment and clinical evaluation of impaired nutritional status and prognosis among hospitalized patients and elders that potentially can contribute to improved patient care and clinical outcomes. However, these novel applications have some technical and physiological limitations that should be considered.

Protein Feeding in Pediatric Acute Kidney Injury Is Not Associated With a Delay in Renal Recovery.

OBJECTIVE: Critically ill children with acute kidney injury (AKI) are at high risk of underfeeding. Newer guidelines for nutrition support recommend higher protein intake. Therefore, the study evaluated the effects of protein feeding on the resolution of AKI and compared energy and protein intake in patients with and without AKI after implementation of Nutrition Support guidelines. DESIGN: Retrospective study. SUBJECTS: Five hundred twenty critically ill children from October 2012 to June 2013 and October to December 2013. MAIN OUTCOME MEASURE: Energy and protein intake in patients with no AKI, resolved, or persistent AKI. Energy and protein intake was documented for days 1-8 of Pediatric Intensive Care Unit stay and in the postimplementation versus preimplementation period of nutrition support guidelines. AKI was defined by modified pRIFLE. Persistent AKI was defined as patients who did not resolve their AKI during the study period. RESULTS: A higher percentage of patients with resolved and persistent AKI met ≥ 80% of protein needs versus no AKI. After adjustment for Pediatric Risk of Mortality Score, the odds ratio for protein intake of ≥ 80% compared to <80% of estimated protein needs was not significant, which suggests that higher protein intake was not associated with nonresolution of AKI. There were significant improvements in the cumulative protein gap in patients with no AKI in the postimplementation (-1.0 [-1.7 to -0.6] g/kg/day) compared to preimplementation period (-1.3 [-1.7 to -0.9] g/kg/day, P = .001) and persistent AKI in the postimplementation (-0.8 [-1.4 to -0.1] g/kg/day) compared to preimplementation (-1.3 [-1.7 to -0.9] g/kg/day, P = .03). CONCLUSIONS: Higher protein intake was not associated with a delay in renal recovery in patients with AKI after adjustment for severity of illness. Protein intake was improved in critically ill children with no AKI, resolved, and persistent AKI after implementation of Nutrition Support Guidelines, but underfeeding persisted in these patients.

Implementation of Nutrition Support Guidelines May Affect Energy and Protein Intake in the Pediatric Intensive Care Unit.

BACKGROUND: Critically ill children are at risk of developing malnutrition, and undernutrition is a risk factor for morbidity and mortality. OBJECTIVE: The study evaluated changes in the energy and protein intake before and after implementation of nutrition support (NS) guidelines for a pediatric critical care unit (PICU). DESIGN: This retrospective study documented energy and protein intake for the first 8 days of PICU stay. Basal metabolic rate and protein needs were estimated by Schofield and American Society for Parenteral and Enteral Nutrition Guidelines, respectively. PARTICIPANTS/SETTING: Three hundred thirty-five children from August to December 2012 (pre-implementation) and 185 from October to December 2013 (post-implementation). INTERVENTION: Implementation of NS Guidelines. MAIN OUTCOME MEASURES: Changes in actual energy and protein intake in the post- compared with the pre-Implementation period. STATISTICAL ANALYSIS PERFORMED: Unpaired t tests, Pearson's χ(2) (unadjusted analysis) were used. Logistic regressions were used to estimate odds ratios and 95% confidence intervals for protein and energy intake, adjusted for age, sex, and Pediatric Risk of Mortality score. RESULTS: After the implementation of guidelines, significant improvements were seen during days 5 through 8 in energy intake among children 2 years of age and older, and in protein intake in both age groups (P<0.05). For the 8-day period, statistically or clinically significant improvements occurred in the cumulative protein deficit/kg/day, as follows: younger than 2-year-olds, -1.5±0.7 g/kg/day vs -1.3±0.8 g/kg/day, P=0.02; 2-year-olds or older, -1.0±0.6 g/kg/day vs -0.7±0.8 g/kg/day, P=0.01; and for the energy deficit/kg/d in 2-year-olds and older, -17.2±13.6 kcal/kg/day vs -13.3±18.1 kcal/kg/day, unpaired t test, P=0.07, in the pre- vs post-implementation period, respectively. CONCLUSIONS: The implementation of NS guidelines was associated with improvements in total energy in 2-year-olds and older and protein in younger than 2 and 2 years and older children by days 5 through 8, and protein deficits were significantly lower in the post- vs the pre-implementation period. The implementation of NS guidelines may have had a positive effect on improving NS in critically ill children.

Growth failure and nutrition considerations in chronic childhood wasting diseases.

Growth failure is a common problem in many children with chronic diseases. This article is an overview of the most common causes of growth failure/growth retardation that affect children with a number of chronic diseases. We also briefly review the nutrition considerations and treatment goals. Growth failure is multifactorial in children with chronic conditions, including patients with cystic fibrosis, chronic kidney disease, chronic liver disease, congenital heart disease, human immunodeficiency virus, inflammatory bowel disease, short bowel syndrome, and muscular dystrophies. Important contributory factors to growth failure include increased energy needs, increased energy loss, malabsorption, decreased energy intake, anorexia, pain, vomiting, intestinal obstruction, and inflammatory cytokines. Various metabolic and pathologic abnormalities that are characteristic of chronic diseases further lead to significant malnutrition and growth failure. In addition to treating disease-specific abnormalities, treatment should address the energy and protein deficits, including vitamin and mineral supplements to correct deficiencies, correct metabolic and endocrinologic abnormalities, and include long-term monitoring of weight and growth. Individualized, age-appropriate nutrition intervention will minimize the malnutrition and growth failure seen in children with chronic diseases.

Perioperative nutritional support and malnutrition in infants and children with congenital heart disease.

OBJECTIVE: To assess the effect of nutritional status and cardiovascular risk on hospital outcomes after congenital heart surgery in infants and children. DESIGN: Retrospective study. SETTING: Cardiac intensive care unit in a tertiary-care children's hospital. PATIENTS: One hundred twenty-one patients <24 months of age admitted to the cardiovascular intensive care unit (CVICU) for >48 hours following cardiac surgery. METHODS: Demographics, Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1), Paediatric Index of Mortality 2, and Pediatric Risk of Mortality III scores were obtained on admission. CVICU nutritional intake was calculated for 7 days. Energy and protein needs were estimated using recommended guidelines. Risk Adjustment for Congenital Heart Surgery-1 was categorized as (1-3) or (4-6). Malnutrition was categorized by Waterlow criteria and correlated with mortality risk, days of mechanical ventilation, and hospital and CVICU length of stay. RESULTS: Ninety-one patients who underwent cardiac surgery were categorized as RACHS-1 (1-3) and RACHS-1 scores of (4-6) (n = 30). Patients with RACHS-1 (4-6) had higher mortality risk by Pediatric Risk of Mortality III (4.9% vs. 2.6%, P < .01), longer CVICU (10.4 days vs. 4.8 days) and hospital stays (28 days vs.14 days), and more days of mechanical ventilation (4 days vs. 2 days) (all P < .005) than RACHS-1 (1-3). The prevalences of acute protein-energy malnutrition and chronic protein-energy malnutrition were 51.2% and 40.5%. The median hospital stay for mild, moderate, and severe chronic protein-energy malnutrition was 31, 10, and 22.5 days, respectively, vs. normal, 15 days (Kruskal-Wallis, P < .005). The average energy and protein requirements met on day 7 were 68 ± 27(SD)% and 68 ± 40%, respectively. CONCLUSION: Although nearly half of the patients were malnourished at surgery, only two-thirds of their recommended caloric and protein requirements were provided by week 1. To improve hospital outcomes, care should be taken to optimize the nutritional condition of infants and children prior to and following surgical correction of congenital heart disease to improve hospital outcomes.

Changes in body composition after lung transplantation in children.

BACKGROUND: The evaluation of nutritional status, including body composition measurements, in pediatric patients before and after lung transplant (LTx) can aid in adapting nutrition support and physical rehabilitation programs to meet individual patient needs. The purpose of this retrospective study was to determine the changes in weight, lean body mass (LBM), and body fat (BF) before and after LTx and their association with lung function in pediatric patients. METHODS: Included were 41 LTx patients, aged 3 months to 20.7 years, who had at least 2 body composition measurements determined by dual-energy X-ray absorptiometry (GE Lunar Prodigy, Waukesha, WI) in the first 2 years after LTx were measured pre-LTX and at 12 or 24 months post-LTX, for weight, LBM, and BF. RESULTS: Pre-LTx, 29% of patients had moderate and 12% had severe chronic malnutrition (growth stunting). This compares with 21% of patients being moderately LBM-depleted and 23% being BF-depleted. The weight change at 12 and 24 months was +9.3% (interquartile range, 5.6%-23%) and +4.7% (0.9%-11.6%), respectively; whereas the LBM change at 12 and 24 months was +15.2% (6.8%-17.1%) and +4.2% (-0.6% to 7.7%), respectively. LBM percentiles correlated with pulmonary function tests ( % predicted forced vital capacity [ρ = 0.36, p = 0.001] and forced expiratory volume in 1 second [ρ = 0.265, p = 0.015). CONCLUSIONS: Maximum weight and LBM gain occur at 12 months after LTx, with smaller gains noted at 24 months. Clinicians must look beyond height and weight and evaluate LBM and fat mass in pediatric patients after LTx.

Nutrition support among critically ill children with AKI.

BACKGROUND: Critically ill children are at high risk of underfeeding and AKI, which may lead to further nutritional deficiencies. This study aimed to determine the adequacy of nutrition support during the first 5 days of intensive care unit (ICU) stay. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A chart review of pediatric patients admitted to the pediatric ICU for >72 hours between August 2007 and March 2008 was conducted. Patients were classified as having no AKI versus AKI by modified pediatric RIFLE criteria. All nutrition was analyzed. Basal metabolic rate (BMR) was estimated by the Schofield equation and protein needs by American Society for Parenteral and Enteral Nutrition guidelines. RESULTS: Of the 167 patients, 102 were male and 65 were female (median age 1.4 years). Using the RIFLE criteria, 102 (61%) patients had no AKI, whereas 44 (26%) were classified as category R (risk), 12 (7%) as category I (injury), and 9 (5%) as category F (failure). The median 5-day energy intake was lower relative to estimated BMR. Overall protein provision (19%) was lower than energy provision (55%) compared with estimated needs (P<0.001). I/F patients were more likely to be fasted versus receiving enteral/parenteral nutrition (n=813 patient days) and to receive <90% of BMR (n=832 patient days) than No AKI/R patients. CONCLUSIONS: Underfeeding, common in critically ill children, was accentuated in AKI. Protein underfeeding was greater than energy underfeeding in the first 5 days of PICU stay. Efforts should be made to provide adequate nutrition in ICU patients with AKI.

Low phase angle determined by bioelectrical impedance analysis is associated with malnutrition and nutritional risk at hospital admission.

BACKGROUND & AIMS: This study determined the association between phase angle (PhA), by bioelectrical impedance analysis (BIA) and nutritional risk by Nutritional Risk Screening (NRS-2002), Subjective Global Assessment (SGA), hospital length of stay (LOS) and 30 day non-survival in patients at hospital admission compared to healthy controls. METHODS: PhA was determined by BIA in patients (n = 983, 52.7 ± 21.5 yrs, M 520) and compared to healthy age-, sex- and height-matched controls. Low PhA was set at <5.0° (men) and <4.6° (women) as previously determined (Kyle, in press). RESULTS: PhA was lower in patients (men 6.0 ± 1.4°, women 5.0 ± 1.3°) than controls (men 7.1 ± 1.2°, women 6.0 ± 1.2°, un-paired t-test p < 0.001). Patients were more likely to have low PhA than controls: NRS-2002: no risk (relative risk (RR) 1.7, 95th confidence interval (CI) 1.2-2.3), moderate risk (RR 4.5, CI 3.4-5.8) and severe risk (RR 7.5, CI 5.9-9.4); similar results were obtained by SGA; LOS ≥21 days (RR 6.9, CI 5.1-9.1) and LOS 5-20 days (RR 5.2, CI 3.9-6.9) and non-survivors (RR 3.1, CI 2.1-3.4) compared to survivors. CONCLUSIONS: There is a significant association between low PhA and nutritional risk, LOS and non-survival. PhA is helpful to identify patients who are at nutritional risk at hospital admission in order to limit the number of in-depth nutritional assessments.

Low fat-free mass as a marker of mortality in community-dwelling healthy elderly subjects.

BACKGROUND: low fat-free mass has been related to high mortality in patients. This study evaluated the relationship between body composition of healthy elderly subjects and mortality. METHODS: in 1999, 203 older subjects underwent measurements of body composition by bioelectrical impedance analysis, Charlson co-morbidity index and estimation of energy expenditure through physical activity by a validated questionnaire. These measurements were repeated in 2002, 2005 and 2008 in all consenting subjects. Mortality data between 1999 and 2010 were retrieved from the local death registers. The relationship between mortality and the last indexes of fat and fat-free masses was analysed by multiple Cox regression models. RESULTS: women's and men's data at last follow-up were: age 81.1 ± 5.9 and 80.9 ± 5.8 years, body mass index 25.3 ± 4.6 and 26.1 ± 3.4 kg/m(2), fat-free mass index 16.4 ± 1.8 and 19.3 ± 1.9 kg/m(2) and fat mass index 9.0 ± 3.2 and 6.8 ± 2.0 kg/m(2). Fifty-eight subjects died between 1999 and 2010. The fat-free mass index (hazard ratio 0.77; 95% confidence interval 0.63-0.95) but not the fat mass index, predicted mortality in addition to sex and Charlson index. The multiple Cox regression model explained 31% of the variance of mortality. CONCLUSION: a low fat-free mass index is an independent risk factor of mortality in elderly subjects, healthy at the time of body composition measurement.

Nutrition support in critically ill children: underdelivery of energy and protein compared with current recommendations.

Critically ill children are at high risk for developing nutritional deficiencies, and hospital undernutrition is known to be a risk factor for morbidity and mortality in children. This study's aims were to examine current nutrition practices and the adequacy of nutrition support in the pediatric intensive care unit (PICU). This retrospective chart review included 240 PICU patients admitted to PICU for longer than 48 hours and documented all intravenous (IV), parenteral, and enteral energy and protein for the first 8 days. Basal metabolic rate and protein requirements were estimated by Schofield equation and the American Society for Parenteral and Enteral Nutrition Clinical Guidelines, respectively. Moderate/severe acute malnutrition was defined as weight for age greater than -2 z scores, and moderate/severe chronic malnutrition (growth stunting) was defined as height for age greater than -2 z scores, using 2000 Centers for Disease Control and Prevention growth charts. During the first 8 days of PICU stay, the actual energy intake for all patient-days was an average of 75.7% ± 56.7% of basal metabolic rate and was significantly lower than basal metabolic rate (P<0.001); the actual protein intake for all patient-days met an average of 40.4% ± 44.2% of protein requirements and was significantly lower than the American Society for Parenteral and Enteral Nutrition guidelines (P<0.001). Delivery of energy and protein were inadequate on 60% and 85% of patient-days, respectively. Only 75% of estimated energy and 40% of protein requirements were met in the first 8 days of PICU stay. These data demonstrate a high prevalence of critically ill children who are not meeting their recommended levels of protein and energy. In order to avoid undernutrition of these children, providers must conduct ongoing assessment of protein and energy intake compared with protein and energy requirements.

Coinfection with Staphylococcus aureus increases risk of severe coagulopathy in critically ill children with influenza A (H1N1) virus infection.

OBJECTIVES: H1N1 influenza with coinfections has been implicated to have high morbidity and mortality. We hypothesized that critically ill children with 2009 H1N1 and coinfections are at a higher risk of developing disseminated intravascular coagulation. DESIGN: The chart review included demographics, length-of-stay, severity of illness score (Pediatric Risk of Mortality III acute physiology score), clinical laboratories, and outcomes at hospital day 90 data. Patients were classified as having methicillin-sensitive or -resistant Staphylococcus aureus, other, or no coinfections. SETTING: Single-center pediatric intensive care unit. PATIENTS: Sixty-six consecutive patients with 2009 H1N1 and influenza A infection. INTERVENTIONS: None. MAIN RESULTS: : There were 12, 22, and 32 patients with methicillin-sensitive or -resistant Staphylococcus aureus, other, and no coinfections, respectively. Pediatric critical care unit length-of-stay was 11, 10, and 5.5 days (median), and survival at day 90 was 83%, 96%, and 91% in patients with methicillin-sensitive or -resistant Staphylococcus aureus, other, and no coinfections. Patients with methicillin-sensitive or -resistant Staphylococcus aureus coinfections compared to patients with other, and no coinfections had higher Pediatric Risk of Mortality III acute physiology scores (14 [6-25] vs. 7 [2-10], p = .052 and 6 [2.5-10], p = .008; median [interquartile range]), higher D-dimer (16.1 [7.9-19.3] vs. 1.6 [1.1-4], p = .02 and 2.3 [0.8-8.7] µg/mL, p = .05), longer prothrombin time (19.3 [15.4-25.9] vs. 15.3 [14.8-17.1], p = .04 and 16.6 [14.7-20.4] secs, p < .39) at admission, and lower day-7 platelet counts (90K [26-161K] vs. 277K [98-314], p = .03 and 256K [152-339]/mm, p < .07). Patients with methicillin-sensitive or -resistant Staphylococcus aureus coinfections compared to patients without coinfections were more likely to be sicker with Pediatric Risk of Mortality III acute physiology score >10 vs. <10 (relative risk 2.4; 95% confidence interval 1.2-4.7; p = .035) and have overt disseminated intravascular coagulation (relative risk 4.4; 95% confidence interval 1.3-15.8, p = .025). CONCLUSIONS: During the 2009-2010 H1N1 pandemic, pediatric patients with influenza A and methicillin-sensitive or -resistant Staphylococcus aureus coinfections were sicker and more likely to develop disseminated intravascular coagulation than patients with other or no coinfections.

Can phase angle determined by bioelectrical impedance analysis assess nutritional risk? A comparison between healthy and hospitalized subjects.

BACKGROUND & AIMS: Low phase angle (PhA) by bioelectrical impedance analysis (BIA), is associated with increased morbidity and nutritional risk. This study determined the cut-off values for PhA compared to Nutritional Risk Screening (NRS-2002) and Subjective Global Assessment (SGA) in patients at hospital admission, and evaluated the association between PhA and serum albumin. METHODS: PhA was determined in patients (Men (M)/Women (W)=382/267), and healthy age-, sex- and height-matched controls. Sensitivity and specificity were calculated for PhA compared to NRS-2002, SGA and serum albumin. The cut-off values were assessed by receiver operator characteristics area under the curve (ROC-AUC). RESULTS: The best PhA cut-offs were 5.0° and 4.6° in M/W. The sensitivity for NRS-2002 was 70.0/58.1% (M/W); SGA: 73.3/64.5%; albumin: 58.8/23.5%; specificity for NRS-2002: 85.1/81.7% (M/W); SGA: 76.6/76.1% and albumin: 93.2/96.6%. The PhA showed a ROC-AUC for NRS-2002 of 0.85/0.80 (M/W); SGA: 0.83/0.80 and albumin: 0.85/0.91. Patients with albumin levels <35 g/L had a relative risk of 7.5 to have low PhA compared to patients with ≥35 g/L CONCLUSIONS: The consistent sensitivity and specificity between PhA and three screening tools strengthens the validity of our study. PhA appears to be a useful screening tool to assess nutritional risk without having to measure weight or height.

Is indirect calorimetry a necessity or a luxury in the pediatric intensive care unit?

BACKGROUND: Critically ill children differ in their energy needs from healthy children in terms of underlying metabolic derangement, comorbidities, energy reserve, and response to illness. This study determined how many pediatric intensive care unit (PICU) patients were candidates for indirect calorimetry (IC), per American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommendations. METHODS: Admission diagnosis, demographics, type/amount of nutrition support, length of intensive care unit/hospital stay were collected. Patients were classified as candidates for IC per A.S.P.E.N. guidelines. RESULTS: Mean (SD) age of patients (n = 150) was 6.7 (5.6) years, with PICU length of stay of 3.9 (5.3) days. IC was indicated in 72.0% (108/150) of patients during PICU days 1-7. Patients with miscellaneous (50%), neurological (73%), respiratory (81%), sepsis (83%), and oncology (100%) diagnoses were candidates for IC. Underweight/overweight/obese (32.4%), hypermetabolism (26.4%), and not meeting nutrition goals (13.7%) were the most frequent indications for IC (χ(2), P < .001). Patients (31%) met ≥2 indications for IC. Patients with neurological disease (relative risk [RR], 4.8; 95% confidence interval [CI], 1.7-14.6), oncology patients (4.2; 1.1-15.9), respiratory patients (5.5; 2.0-16.9), and children with sepsis/septic shock/infection (5.6; 1.9-18.1) were more likely to have ≥2 indications for IC compared to those with other diagnoses. CONCLUSIONS: Three of 4 patients were candidates for IC per A.S.P.E.N. guidelines. PICUs might have to prioritize performing IC in patients who are <2 years of age, malnourished (underweight/overweight) on admission, or PICU stay of >5 days. Future studies should determine the cost-benefit ratios of performing IC in PICU patients.

Progressive regression of left ventricular hypertrophy two years after bariatric surgery.

BACKGROUND: Obesity is a systemic disorder associated with an increase in left ventricular mass and premature death and disability from cardiovascular disease. Although bariatric surgery reverses many of the hormonal and hemodynamic derangements, the long-term collective effects on body composition and left ventricular mass have not been considered before. We hypothesized that the decrease in fat mass and lean mass after weight loss surgery is associated with a decrease in left ventricular mass. METHODS: Fifteen severely obese women (mean body mass index [BMI]: 46.7+/-1.7 kg/m(2)) with medically controlled hypertension underwent bariatric surgery. Left ventricular mass and plasma markers of systemic metabolism, together with body mass index (BMI), waist and hip circumferences, body composition (fat mass and lean mass), and resting energy expenditure were measured at 0, 3, 9, 12, and 24 months. RESULTS: Left ventricular mass continued to decrease linearly over the entire period of observation, while rates of weight loss, loss of lean mass, loss of fat mass, and resting energy expenditure all plateaued at 9 [corrected] months (P <.001 for all). Parameters of systemic metabolism normalized by 9 months, and showed no further change at 24 months after surgery. CONCLUSIONS: Even though parameters of obesity, including BMI and body composition, plateau, the benefits of bariatric surgery on systemic metabolism and left ventricular mass are sustained. We propose that the progressive decrease of left ventricular mass after weight loss surgery is regulated by neurohumoral factors, and may contribute to improved long-term survival.

Organ dysfunction is associated with hyperglycemia in critically ill children.

OBJECTIVE: To determine the association between organ dysfunction and hyperglycemia in critically ill children receiving intravenous insulin. DESIGN: Retrospective chart review (cohort study). SETTING: Pediatric intensive care unit in a university hospital. PATIENTS: n = 110 patients; inclusion criteria: ICU hospitalization from May 2005 to May 2006; insulin drip to manage hyperglycemia. EXCLUSION CRITERIA: insulin drip <48 h; diabetic patients. MEASUREMENTS: Duration of hyperglycemia: sum of hours of hyperglycemia (> or =126 mg/dl). Hypoglycemia (blood glucose <40 mg/dl). Organ dysfunction was determined per International Pediatric Sepsis Consensus Conference criteria. Multiple logistic regression models determined the association between > or =3 compared to <3 organ dysfunctions and hyperglycemia, hypoglycemia, and mortality, after adjustment for confounding variables (age, gender, PRISM score, vasopressors, steroids). MAIN RESULTS: Organ dysfunction > or =3 compared to <3 after adjustment for confounders was associated with intermittent hyperglycemia of > or =24 h (OR 6.1, CI 1.8-21.2; p = 0.004). Hyperglycemia trended towards significance with mortality [3.2 (CI 0.9-11.6, p = 0.079)]. Hypoglycemia, after adjusting for the above, was not associated with mortality. CONCLUSIONS: Organ dysfunction (> or =3 versus <3) was significantly associated with hyperglycemia for > or =24 h and hypoglycemia. Hyperglycemia trended toward significance with mortality in critically ill children. There was no association between hypoglycemia and mortality.

Overweight and obesity in a Swiss city: 10-year trends.

BACKGROUND: Increased rates of overweight/obesity have been reported in recent years in developed countries. This population study of healthy subjects evaluated the changes in overweight/obesity prevalence in 2003, compared with 1993, and determined the association of age, sex and leisure-time activity with body mass index (BMI), fat-free mass index (FFMI) and fat mass index (FMI). DESIGN: Two transversal samples of convenience. PARTICIPANTS: Healthy volunteers (1993, n = 802; 2003, n = 1631). METHODS: Fat-free mass was determined using the bioelectrical impedance multiple regression equation. Multivariable linear regression, including confounding variables (age, sex, leisure-time activity), was used to model the body composition evolution between the 1993 and the 2003 subjects. RESULTS: BMI and FMI were higher in 2003 than in 1993, P < 0.001. FFMI was not higher in 2003 than in 1993, P = 0.38. More subjects were overweight/obese in 2003 than in 1993 (27.5 versus 17.2%, chi-square P < 0.001), and had a high FFMI (30.2 versus 21.8%, chi-square P < 0.001) and high FMI (28.0 versus 20.3%, chi-square P < 0.001). Multivariate linear regressions showed that leisure-time activity was negatively, and sex, age and inclusion year were positively associated with BMI, FFMI and FMI (the exception was a negative association with sex) (P < 0.001). CONCLUSION: Overweight prevalence increased between 1993 and 2003 in a Swiss city, and was associated with a higher fat mass. This observation remained statistically significant after adjustment for age, sex and leisure-time activity.

Longitudinal study of body composition changes associated with weight change and physical activity.

OBJECTIVE: Weight changes result in fat-free mass (FFM) and body fat (BF) changes. This study determined FFM and BF changes after weight gain or loss and whether these changes differ by gender, physical activity, and age. METHODS: Healthy volunteers, recruited between 1991 and 2003, were followed for 1 y (n = 400) or 3 y (n = 305). Active subjects performed >3 h of physical activity of > or =4.0 metabolic equivalents/wk, sedentary subjects performed <3 h/wk. Body weight and body composition by bioelectrical impedance analysis were determined at year 0, 1, or 3. RESULTS: At years 1 and 3, FFM and BF decreased with weight loss and increased with weight gain. BF was more sensitive (P < 0.03) to weight change than FFM. Compared to weight-stable individuals at year 1, weight gains of 1.0-1.9, 2.0-2.9, and > or =3.0 kg changed FFM by -0.04 (P = 0.90), +0.48 (P = 0.15), and +1.39 kg and BF by +1.35, +1.87, and +3.09 kg, respectively (all P < 0.001). Comparable FFM and BF decreases were observed for weight losses (FFM -0.28 kg, P = 0.38; -0.75 kg, P = 0.04; -1.51 kg, P < 0.001; BF -1.01 kg, P < 0.01; -1.55 kg, P = 0.01; -3.13 kg, P < 0.001). These relations were similar across gender and age strata. At year 1, active individuals were less likely to gain BF with weight gain and more likely to lose BF with weight loss than were sedentary individuals, except for weight losses >3 kg. At year 3, the association between body weight and FFM and BF change was similar between active and sedentary individuals. CONCLUSION: Greater weight changes (>3 kg) are necessary for weight change to have a significant effect on FFM than to have an effect on BF.

The Dutch Famine of 1944-1945: a pathophysiological model of long-term consequences of wasting disease.

PURPOSE OF REVIEW: The tragic circumstances of the Dutch Hunger Winter of 1944-1945 created a unique opportunity to study the relation between exposure to prenatal famine and health in adult life. This review addresses the literature on the effects of maternal malnutrition during the different periods of gestation and childhood on health in adult life. RECENT FINDINGS: Exposure to famine during gestation resulted in increases in impaired glucose tolerance, obesity, coronary heart disease, atherogenic lipid profile, hypertension, microalbuminuria, schizophrenia, antisocial personality and affective disorders. Exposure to famine during childhood resulted in changes in reproductive function, earlier menopause, changes in insulin-like growth factor-I and increases in breast cancer. SUMMARY: Exposure to famine during gestation and childhood has life-long effects on health, and these effects vary depending on the timing of exposure as well as evolution of the recovery period.

Hospitalized mechanically ventilated patients are at higher risk of enteral underfeeding than non-ventilated patients.

BACKGROUND & AIMS: Enteral nutrition (EN) is the preferred method of nutrition support in hospitalized patients but only 50-90% of the required calories are actually delivered. In order to identify where our nutrition support team (NST) should focus its activity, we prospectively evaluated the level of coverage of energy and protein needs during the first 5 days of EN in intensive care unit (ICU) and non-ICU patients and the relationship of energy and protein coverage with serum albumin, transthryretin, insulin-like growth factor-1 (IGF-1) and C-reactive protein (CRP). METHODS: Subjects (n=183) who required nutrition support and received EN were prospectively recruited. Calorie prescription was 20 and 25, 25 and 30 kcal/kg BW for women and men 60 years and <60 years, respectively. Protein needs were estimated as 1.2g protein/kg BW. Logistic regression analysis was used to estimate odds ratios (OR) for energy and protein delivery 66.6% and <66.6% and albumin, transthryretin, IGF-1 (low vs. normal) and CRP (high vs. normal) in ventilated vs. non-ventilated patients. RESULTS: Significantly more mechanically ventilated than non-ventilated patients received <66.6% of energy (71% vs. 48%) and protein (96% vs. 65%). The ventilated patients were more likely to be energy (OR 2.1, CI 1.1-4.0) and protein (OR 15.7, CI 4.9-50.8) underfed than non-ventilated patients. There was a significant association on day 5 between low protein delivery and low albumin (OR 2.9, CI 1.3-6.5), low transthyretin (OR 3.0, CI 1.4-6.5), low IGF-1 (OR 2.8, CI 1.2-6.7) and high CRP (OR 3.5, CI 1.6-7.8). CONCLUSIONS: The energy and protein needs of hospitalized patients are not met during the first 5 days of EN. Ventilated patients are more likely to be energy and protein underfed than non-ventilated patients and to have low plasma protein level. These findings support our decision to intensify EN monitoring by our NST in ventilated patients to optimize their nutritional coverage.