Criteria for classification of protein-energy wasting in dialysis patients: impact on prevalence.

Malnutrition is highly prevalent in dialysis patients and associated with poor outcomes. In 2008, protein-energy wasting (PEW) was coined by the International Society of Renal Nutrition and Metabolism (ISRNM), as a single pathological condition in which undernourishment and hypercatabolism converge. In 2014, a new simplified score was described using serum creatinine adjusted for body surface area (sCr/BSA) to replace a reduction of muscle mass over time in the muscle wasting category. We have now compared PEW-ISRNM 2008 and PEW-score 2014 to evaluate the prevalence of PEW and the risk of death in 109 haemodialysis patients. This was a retrospective analysis of cross sectional data with a median prospective follow-up of 20 months. The prevalence of PEW was 41 % for PEW-ISRNM 2008 and 63 % for PEW-score 2014 (P <0·002). Using PEW-score 2014: twenty-nine patients (27 %) had severe malnutrition (PEW-score 2014 0-1) and forty (37 %) with moderate malnutrition (score 2). Additionally, thirty-three (30 %) patients had mild wasting and only seven patients (6 %) presented a normal nutritional status. sCr/BSA correlated with lean total mass (R 0·46. P<0·001). A diagnosis of PEW according to PEW-score 2014, but not according to PEW-ISRNM 2008, was significantly associated with short-term mortality (P=0·0349) in univariate but not in multivariate analysis (P=0·069). In conclusion, the new PEW-score 2014 incorporating sCr/BSA identifies a higher number of dialysis PEW patients than PEW-ISRNM 2008. Whereas PEW-score-2014 provides timelier and therefore more clinically relevant information, its association with early mortality needs to be confirmed in larger studies.

Forensic aspects of starvation.

Fatal starvation is a rare cause of death in industrialized countries. However, it may have major medicolegal importance if death results from the deliberate withholding of food, especially from infants. In such cases, the task of the forensic pathologist and the medical examiner, respectively, is to clarify the cause of death and give an expert opinion on the degree and duration of starvation. Several classification systems have been developed to estimate protein-energy malnutrition in developing countries. Simpler classifications, such as the Gomez classification, use the weight expected for the respective age group as the standard. However, smaller infants will be lighter, and therefore the classification may not be accurate in this case. Following the Waterlow classification, the extent of stunted growth (referring to growth retardation in cases of chronic malnutrition) is calculated using the ratio of the measured body height to that expected for the age. Using such classification systems, grading of stunting and wasting can be achieved and may greatly help in the assessment of a given child's nutritional status in legal cases. The application of the Waterlow classification to the authors' case material and previously published cases in the literature is herein demonstrated. The Waterlow classification is not only of importance for grading the final stage of fatal starvation, but also for the chronological development of the nutritional status if anthropometrical data have been repeatedly recorded from the affected individual in vivo.

A practical approach to classifying and managing feeding difficulties.

Many young children are thought by their parents to eat poorly. Although the majority of these children are mildly affected, a small percentage have a serious feeding disorder. Nevertheless, even mildly affected children whose anxious parents adopt inappropriate feeding practices may experience consequences. Therefore, pediatricians must take all parental concerns seriously and offer appropriate guidance. This requires a workable classification of feeding problems and a systematic approach. The classification and approach we describe incorporate more recent considerations by specialists, both medical and psychological. In our model, children are categorized under the 3 principal eating behaviors that concern parents: limited appetite, selective intake, and fear of feeding. Each category includes a range from normal (misperceived) to severe (behavioral and organic). The feeding styles of caregivers (responsive, controlling, indulgent, and neglectful) are also incorporated. The objective is to allow the physician to efficiently sort out the wide variety of conditions, categorize them for therapy, and where necessary refer to specialists in the field.

Malnutrition coding 101: financial impact and more.

Recent articles have addressed the characteristics associated with adult malnutrition as published by the Academy of Nutrition and Dietetics (the Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). This article describes a successful interdisciplinary program developed by the Department of Food and Nutrition at New York-Presbyterian Hospital to maintain and monitor clinical documentation, ensure accurate International Classification of Diseases 9th Edition (ICD-9) coding, and identify subsequent incremental revenue resulting from the early identification, documentation, and treatment of malnutrition in an adult inpatient population. The first step in the process requires registered dietitians to identify patients with malnutrition; then clear and specifically worded diagnostic statements that include the type and severity of malnutrition are documented in the medical record by the physician, nurse practitioner, or physician's assistant. This protocol allows the Heath Information Management/Coding department to accurately assign ICD-9 codes associated with protein-energy malnutrition. Once clinical coding is complete, a final diagnosis related group (DRG) is generated to ensure appropriate hospital reimbursement. Successful interdisciplinary programs such as this can drive optimal care and ensure appropriate reimbursement.

Biosocial comparison of mid-upper arm circumference in the two Koreas.

Anthropometric differences between the two Koreas are of considerable public and scientific interest given the unique socio-political status of North Korea and the fact that the nations share the same genetic ancestry. This study provides new biosocial evidence on these differences by analysing mid-upper arm circumference (MUAC) as a human welfare indicator. This is the first study to compare the nutritional status of adults surveyed inside North Korea with South Koreans. The MUAC measurements of 2793 North Korean women obtained through a household survey conducted in 2002 were compared with those of 1428 South Korean women surveyed around 2003. Comparative analysis was conducted by plotting centiles and calculating mean differences in MUAC by age. This paper finds that the MUAC of the South Koreans was on average 2.8 cm greater than that of their North Korean peers, with MUAC gaps ranging from 1.6 cm to 3.9 cm and becoming more pronounced with age. This research confirms previous studies on height and weight in the two Germanies and in the two Koreas that have shown that biosocial performance is worse in socialist economies as compared with free-market regimes.

Prevalence of protein-energy wasting and its various types in Iranian hemodialysis patients: a new classification.

BACKGROUND: This study was designed to determine the prevalence of protein-energy wasting (PEW) and its various types in hemodialysis (HD) patients in Tehran, Iran. METHODS: For this cross-sectional study, 291 HD patients were randomly selected. The nutritional status of the patients was determined by subjective global assessment (SGA) and their dietary intakes were assessed using a 4-day dietary recall. In addition, serum high-sensitive C-reactive protein (hs-CRP) was measured. RESULTS: The prevalence of mild-to-moderate and severe PEW based on SGA was 60.5% and 1% in Tehran HD patients, respectively. The prevalence of various types of PEW in HD patients was 20.5% type I (inadequate energy or protein intake without inflammation), 65.5% type IIa (inadequate energy or protein intake with inflammation), and 14% type IIb (adequate energy and protein intake with inflammation). Of the total HD patients with no PEW based on SGA, about 3.5% had type 0 normal nutritional status (adequate energy and protein intake without inflammation), 34% had type I normal nutritional status (inadequate energy or protein intake without inflammation), 55.5% had type IIa normal nutritional status (inadequate energy or protein intake with inflammation), and 7% had type IIb normal nutritional status (adequate energy and protein intake with inflammation). CONCLUSION: PEW in Tehran HD patients is considerably prevalent and PEW type IIa is the most common type. In addition, HD patients with no PEW based on SGA should also be paid attention because they may be in the early stages of inadequate intake of energy and/or protein and inflammation.

Antropometría en niños de la consulta externa del Hospital Universitario del Valle de Cali, Colombia, según la OMS / Anthropometry in children ambulatory from Hospital Universitario del Valle

Objetivo: Valorar por medio de antropometría, a los niños que asisten a la Consulta Externa del Hospital Universitario del Valle “Evaristo García” (HUV) de Cali, Colombia por medio de los patrones de crecimiento infantil de la OMS entre el 1 de julio y el 31 de diciembre de 2010. Materiales y Métodos: Estudio descriptivo observacional no experimental (N=214 niños), edad (E) entre los 0 meses y 17 años, que asistieron al HUV. Se dividieron en 3 grupos: 0 meses a 2 años; >2 años a 4 años y 11 meses, y 5 a 18 años. Se le realizó una historia clínica completa, peso (P), talla (T) y perímetro cefálico (PC) y diagnóstico de primera vez según sistema comprometido. Se aplicó el software Nutritional Statistical System (NSS)®, el cual utiliza como guía de referencia los patrones de crecimiento infantil de la OMS, teniendo como indicadores antropométricos para cada grupo de edad el P/E, el P/T, la T/E, el Índice de masa corporal (IMC), y el PC/E y PC/T. Se realizó su análisis estadístico como porcentajes, promedios, moda, me d i a , me diana y desviación estándar. Conclusiones: Todos los indicadores antropométricos utilizados estuvieron afectados con algún tipo de déficit nutricional, siendo el IMC el menos afectado con un 24,5% y el más afectado es el P/E con un 58,1%. En cuanto a los excesos nutricionales, se encontró que el sobrepeso y la obesidad presentan porcentajes de 17,3% y 3,1% respectivamente. Según los diagnósticos de primera vez, la anomalía con mayor porcentaje de tipo respiratorio con el 18,2%. El indicador PC se utilizó para correlacionarlo con la E, pero es aconsejable utilizarlo igualmente para la talla, lo que podría dar un mejor criterio de diagnóstico.

Objective: To assess through anthropometry, children attending the outpatient clinic of the Hospital Universitario del Valle "Evaristo Garcia" (HUV) Cali, Colombia through the Child Growth Standards WHO between July 1 and on December 31, 2010. Materials and Methods: Descriptive observational nonexperimental (N = 214 children), aged (A) 0 months to 17 years, who attended the HUV. They were divided into 3 groups: 0 months to 2 years; > 2 years to 4 years and 11 months, and 5 to 18 years. They underwent a complete medical history, weight (W), height (H) and head circumference (HC) and the first time as diagnosis of compromised system. Nutritional software was applied, which uses as a reference guide to childhood growth patterns by WHO, with the anthropometric indicators for each age group the W/A, W/H, H/A, BMI, and HC/A and HC/H. Statistical analysis was performed as percentages, averages, mode, mean, median and standard deviation. Conclusions: All anthropometric indicators used were affected with some type of nutritional deficiency, with a BMI less affected with 24.5% and the most affected is the W/A 58.1%. In terms of nutritional excesses, it was found that overweight and obesity have percentages of 17.3% and 3.1% respectively. According to the first diagnosis of the anomaly with the greatest percentage of respiratory type with 18.2%. The indicator HC was used to correlate with A, but it is advisable to use also for H, which could give a better diagnostic criteria.

Serum lipid profile in malnourished Nigerian children in Zaria.

BACKGROUND/OBJECTIVE: There is paucity of data on the pattern of serum lipids in malnourished children in Zaria. Most of the reported studies were carried out in southern part of Nigeria. The overall objective of this study was therefore to measure serum lipids in children with PEM in Zaria with the view to recommending its use in them. SUBJECTS, MATERIALS AND METHODS: Serum lipids were measured in 115 children presenting with PEM and 115 age- and sex-matched well nourished controls aged 6-36 months .The malnourished children consisted of 25, 30, 30 and 30 children with kwashiorkor, marasmic-kwashiorkor, marasmus and underweight respectively. There were 60 males and 55 females. Serum total cholesterol(TC),high density lipoprotein cholesterol (HDL-C) and triglyceride(TG) were measured by enzymatic colorimetric methods of serum low density lipoprotein cholesterol(LDL-C) and very low density lipoprotein cholesterol(VLDL-C) were estimated using Friedewald formula. RESULTS: Serum TC, LDL-C and HDL-C levels were significantly lower (p<0.01, p<0.05 and p<0.001 respectively), while the ratio TC/HDL-C was significantly higher (p<0.001) in children with PEM than in their well-nourished counterparts. Concentrations of serum TG and VLDL-C were apparently but not significantly lower in children with PEM than in well-fed children (p>0.05).Serum levels of TC, LDL-C and HDL-C were significantly higher (p<0.001, p<0.001 and p<0.01 respectively) in oedematous PEM patients than in their non-oedematous counterparts. Serum TG and VLDL-C values were apparently but not significantly higher in oedematous PEM patients than in non-oedematous ones. CONCLUSION: There was a significant reduction in serum lipid concentrations in children with PEM. The study therefore suggests that measurement of serum lipids could be of importance in the assessment of childhood malnutrition.

Assessment of nutritional status of pre-schoolers in slum areas of Udaipur City.

The present study was conducted in pre-schoolers (2-6 years) from ten different slums of Udaipur City in Rajasthan with the aim to their nutritional status. From the data collected and observations recorded was observed that majority of the subjects were from nuclear family with monthly family income of less than Rs.1500/-. Developmental pattern of these subjects indicated that the height with age of bothe male and female subjects increased, however, their body weight did not increase. More than 50% of these pre-schoolers showed symptoms of protein energy malnutrition and anaemia, while 22% had pigeon chest deformity due to vitamin D and calcium deficiency. Classification for degree of malnutrition as per IAP showed that majority of these subjects (66%) were under weight (Grade I and II). Waterlow's classification revealed that majority of these pre-schoolers were wasted (30%) or wasted and Stunted (42%). This malnutrition was either of PCM (past chronic) or CLM (current long duration) type as per Seoane and Latham's classification.

Alteraciones cromosómicas en niños con malnutrición proteico-energética: resultados preliminares / Chromosomic alterations in child by malnutrition energetics-proteine: results preliminary

Objetivos: algunos autores encontraron una relación entre la Malnutrición Proteico Energética (MPE) y elaumento de la frecuencia de Aberraciones Cromosómicas Estructurales (ACE) en niños menores de 5 años.El objetivo del siguiente trabajo es analizar la incidencia de ACE en una población de niños del partido de La Plata que presentan MPE. Material y Métodos: se tomó una muestra de 30 niños de 1 a 60 meses de edad cronológica, 15 controles sanos y 15 diagnosticados como MPE primarios a través de una evaluación antropométrica y clínica. Se aplicó una encuesta semiestructurada en la que se tuvieron en cuenta peso al nacimiento, variables antropométricas, alimentación, enfermedades virales, y/o infecciosas y exposición a agentes potencialmente genotóxicos. Se realizaron cultivos de sangre periférica y se analizó la frecuencia de ACE en 100 células por individuo. Los resultados obtenidos fueron sometidos a evaluación estadística utilizando el programa Epi Info 6.0. Resultados: la diferencia en la frecuencia global de ACE entre ambas muestras resultó significativa. Al tratar cada tipo de aberración en forma independiente se encontraron diferencias significativas para gaps y fracturas de mono e isocromátidas, cromosomas dicéntricos, fragmentos y asociaciones telométricas. No se encontraron diferencias significativas respecto a la exposición de los niños a agentes potencialmente genotóxicos tales como medicamentos, radiaciones, pesticidas y desechos industriales. Conclusiones: la MPE es capaz de inducir daño genotóxico, este efecto podria explicarse por la distorsión del ambiente químico interno o bien por la disminución de la acción de los mecanismos de reparación del ADN como consecuencia del déficit proteico

Alteraciones cromosómicas en niños con malnutrición proteico-erengética: resultados preliminares / Chromosomic alterations in child by malnutrition energetics-proteine: results preliminary

Objetivos: algunos autores encontraron una relación entre la Malnutrición Proteico Energética (MPE) y elaumento de la frecuencia de Aberraciones Cromosómicas Estructurales (ACE) en niños menores de 5 años.El objetivo del siguiente trabajo es analizar la incidencia de ACE en una población de niños del partido de La Plata que presentan MPE. Material y Métodos: se tomó una muestra de 30 niños de 1 a 60 meses de edad cronológica, 15 controles sanos y 15 diagnosticados como MPE primarios a través de una evaluación antropométrica y clínica. Se aplicó una encuesta semiestructurada en la que se tuvieron en cuenta peso al nacimiento, variables antropométricas, alimentación, enfermedades virales, y/o infecciosas y exposición a agentes potencialmente genotóxicos. Se realizaron cultivos de sangre periférica y se analizó la frecuencia de ACE en 100 células por individuo. Los resultados obtenidos fueron sometidos a evaluación estadística utilizando el programa Epi Info 6.0. Resultados: la diferencia en la frecuencia global de ACE entre ambas muestras resultó significativa. Al tratar cada tipo de aberración en forma independiente se encontraron diferencias significativas para gaps y fracturas de mono e isocromátidas, cromosomas dicéntricos, fragmentos y asociaciones telométricas. No se encontraron diferencias significativas respecto a la exposición de los niños a agentes potencialmente genotóxicos tales como medicamentos, radiaciones, pesticidas y desechos industriales. Conclusiones: la MPE es capaz de inducir daño genotóxico, este efecto podria explicarse por la distorsión del ambiente químico interno o bien por la disminución de la acción de los mecanismos de reparación del ADN como consecuencia del déficit proteico

Desnutrición primaria y competencia inmunológica. Verdadera inmunodeficiencia, polarización adaptativa hacia una respuesta Th2 o ambas? / Primary malnutrition and immunological competence. Real immunodeficiency, adaptive TH2-biased responses or both?

La asociación entre malnutrición e infección ha sido reconocida desde hace tiempo. En estudios de terreno se demostró que los individuos malnutridos presentan mayor cantidad de infecciones pulmonares y enterales y un aumento de la mortalidad en el largo plazo a consecuencia de infecciones. Las infecciones contribuyen a empeorar el estado nutricional, y la malnutrición favorece la ocurrencia de infecciones. El hacinamiento, la mala calidad y conservación de los alimentos, su contaminación y la del agua, las dificultades en el acceso a la consulta médica y aún razones culturales que favorecen las medicinas "alternativas" son algunos de los factores responsables. También se ha postulado una disfunción inmune como parte esencial de este fenómeno. En lo que respecta a las varias anomalías inmunológicas reportadas en asociación a la malnutrición cabe hacer algunas consideraciones: Los pacientes reportados son en general moderada o severamete desnutridos y frecuentemente afectados de infecciones concomitantes. La corrección de la desnutrición, asociada a la mejoría de las variables inmunológicas, usualmente fue acompañada de tratamiento de las infecciones bacterianas y parasitarias concomitantes. Los estudios inmunológicos reportados detectan diferencias entre la población bien nutrida (controles) y los individuos malnutridos. Los efectos de la sobreexposición a niveles elevados de contaminación y de la presencia eventual de infecciones clínicas o subclínicas, parasitarias y bacterianas, frecuentemente presentes en individuos desnutridos, son difíciles de evaluar. La causa mas importante de infecciones reiteradas en niños no es la disfunción inmune sino la elevada exposición de microorganismos. Las infecciones severas pueden verse en huespedes inmunologicamente normales. Solamente las infecciones oportunistas se presentan casi exclusivamente en individuos inmunodeficientes. Las anomalías mas frecuentemente descriptas en desnutridos se sitúan en las áreas del complemento, fagocítica y de la inmunidad mediada por células. La inmunidad humoral se ha encontrado habitualmente conservada. Algunas de las anomalías inmunológicas presentes en el huésped desnutrido están probablemente ligadas a las múltiples deficiencias nutricionales presente en la malnutrición severa y representan verdaderos defectos inmunológico

Desnutrición primaria y competencia inmunológica. Verdadera inmunodeficiencia, polarización adaptativa hacia una respuesta Th2 o ambas? / Primary malnutrition and immunological competence. Real immunodeficiency, adaptive TH2-biased responses or both?

La asociación entre malnutrición e infección ha sido reconocida desde hace tiempo. En estudios de terreno se demostró que los individuos malnutridos presentan mayor cantidad de infecciones pulmonares y enterales y un aumento de la mortalidad en el largo plazo a consecuencia de infecciones. Las infecciones contribuyen a empeorar el estado nutricional, y la malnutrición favorece la ocurrencia de infecciones. El hacinamiento, la mala calidad y conservación de los alimentos, su contaminación y la del agua, las dificultades en el acceso a la consulta médica y aún razones culturales que favorecen las medicinas "alternativas" son algunos de los factores responsables. También se ha postulado una disfunción inmune como parte esencial de este fenómeno. En lo que respecta a las varias anomalías inmunológicas reportadas en asociación a la malnutrición cabe hacer algunas consideraciones: Los pacientes reportados son en general moderada o severamete desnutridos y frecuentemente afectados de infecciones concomitantes. La corrección de la desnutrición, asociada a la mejoría de las variables inmunológicas, usualmente fue acompañada de tratamiento de las infecciones bacterianas y parasitarias concomitantes. Los estudios inmunológicos reportados detectan diferencias entre la población bien nutrida (controles) y los individuos malnutridos. Los efectos de la sobreexposición a niveles elevados de contaminación y de la presencia eventual de infecciones clínicas o subclínicas, parasitarias y bacterianas, frecuentemente presentes en individuos desnutridos, son difíciles de evaluar. La causa mas importante de infecciones reiteradas en niños no es la disfunción inmune sino la elevada exposición de microorganismos. Las infecciones severas pueden verse en huespedes inmunologicamente normales. Solamente las infecciones oportunistas se presentan casi exclusivamente en individuos inmunodeficientes. Las anomalías mas frecuentemente descriptas en desnutridos se sitúan en las áreas del complemento, fagocítica y de la inmunidad mediada por células. La inmunidad humoral se ha encontrado habitualmente conservada. Algunas de las anomalías inmunológicas presentes en el huésped desnutrido están probablemente ligadas a las múltiples deficiencias nutricionales presente en la malnutrición severa y representan verdaderos defectos inmunológico

Intraerythrocytic potassium levels and early insulin release in children with moderate malnutrition.

Potassium deficiency and insulin releasing defect in severe protein-energy malnutrition (PEM) have been reported previously. The aim of this study was to investigate the existence of potassium deficiency and early insulin releasing defect in moderate PEM, which is more common in children. This study was carried out prospectively in the Pediatrics Department at Trakya University. The study group comprised 30 children with moderate PEM who were also classified as stunted, wasted, and stunting-wasting. Thirty healthy children were selected as controls. Although there was no statistical difference between the study and control groups in terms of serum potassium and initial insulin levels, intraerythrocytic potassium and early insulin release in patients were significantly lower than in controls. The stunting-wasting cases had the lowest intraerythrocytic potassium and early insulin response to intravenous glucose administration. This study suggests that it is appropriate to evaluate moderate PEM cases for intraerythrocytic potassium deficiency and early insulin releasing defect. Potassium supplements should be given if necessary.

Sweat test results in children with primary protein energy malnutrition.

OBJECTIVES: In underdeveloped and developing countries where protein energy malnutrition (PEM) is common, it is sometimes difficult to exclude the diagnosis of cystic fibrosis (CF) in malnourished children because both primary PEM and CF share similar symptoms, signs, and laboratory findings, such as elevated sweat chloride value. This study was performed to investigate sweat test results and determine percentile values in children with primary PEM. METHODS: A total of 90 children with PEM and 30 healthy children were included. PEM was classified according to criteria defined by Gomez, Waterlow, and McLaren. Sweat tests were performed using the Macroduct conductivity system. RESULTS: Patient age and gender did not affect the test results (P > 0.05). The mean sweat conductivity (equivalent NaCl mMol/L) of patients with PEM was higher than that of controls (P < 0.001) and increased with the degree of malnutrition (P < 0.001). Inverse correlations between sweat conductivity and weight for age, height for age, and weight for height were detected (P < 0.001). The highest value was found in children with wasting and stunting, followed by those with stunting (P < 0.05) and those with marasmic kwashiorkor (P < 0.01). Of all children with PEM, 6.7% had elevated sweat test results that normalized after nutritional management; of children with third degree PEM, the figure was 20%. Ninety-fifth percentile values of first, second, and third degree malnutrition were 47 mMol/L, 49 mMol/L, and 69 mMol/L, respectively. CONCLUSION: Elevated sweat test result is not an important problem, especially in first and second degree PEM, but borderline values can be detected in as many as 20% of cases of third degree malnutrition. Sweat conductivity may increase to 69 mMol/L in children with stunting, those with wasting and stunting, and in those with third degree PEM.

Impact of nutritional rehabilitation on enzymatic antioxidant levels in protein energy malnutrition.

To assess the role of enzymatic antioxidants in the pathogenesis of protein energy malnutrition (PEM) and the effect of nutritional rehabilitation, we studied 30 infants with PEM (mean age 10.63 +/- 4.39 months: 10 marasmic; 8 with kwashiorkor; 12 with marasmic kwashiorkor) and 15 controls. All underwent clinical examination and laboratory investigations, including superoxide dismutase (SOD) and glutathione peroxidase (GPx) estimation before and after nutrition rehabilitation. SOD and GPx were significantly lower in all malnourished infants compared to controls, and significantly increased after nutritional rehabilitation. These significant correlations suggest that antioxidants could be introduced during PEM nutritional rehabilitation to decrease morbidity and mortality.