Role of Oral Nutritional Supplements Enriched with ß-Hydroxy-ß-Methylbutyrate in Maintaining Muscle Function and Improving Clinical Outcomes in Various Clinical Settings.

Aging and disease-related malnutrition are well associated with loss of muscle mass and function. Muscle mass loss may lead to increased health complications and associated increase in health care costs, especially in hospitalized individuals. High protein oral nutritional supplements enriched with ß-hydroxy-ß-methylbutyrate (HP-ONS+HMB) have been suggested to provide benefits such as improving body composition, maintaining muscle mass and function and even decreasing mortality rates. The present review aimed to examine current evidence on the effect of HP-ONS+HMB on muscle-related clinical outcomes both in community and peri-hospitalization patients. Overall, current evidence suggests that therapeutic nutrition such as HP-ONS+HMB seems to be a promising tool to mitigate the decline in muscle mass and preserve muscle function, especially during hospital rehabilitation and recovery.

Post-lunch triglyceridaemia associates with HDLc and insulin resistance in fasting normotriglyceridaemic menopausal women.

OBJECTIVES: Post-prandial hypertriglyceridaemia (P-HTG) is associated with cardiovascular disease. This association is of paramount importance during menopause, which is also related to reduced high-density lipoprotein-cholesterol (HDLc) and elevated triglyceride (TG) levels. We aimed to provide a self-assesing tool to screen for P-HTG in menopausal women who were normotriglyceridaemic at fasting and adhered to a Mediterranean-style eating pattern. METHODS: We performed oral fat loading tests (OFLT) in combination with self-measurements of diurnal capillary TG at fixed time-points (DC-TG) in 29 healthy menopausal women. TG levels >220 mg dL-1 at any given time during the OFLT served as diagnostic criteria for P-HTG. Subsequently, DC-TG profiles were examined to determine the best mealtime (breakfast, lunch or dinner), as well as optimal cut-off points to classify these women as having P-HTG according to the OFLT. Insulin resistance was defined as the upper tertile of the homeostatic model assessment of insulin resistance. RESULTS: We found that, despite having normal fasting TG levels, P-HTG was highly prevalent (approximately 40%). Moreover, self-assessed 3-h post-lunch TG levels >165 mg dL-1 increased the odds of having hypo-HDL cholesterolaemia by 14.1-fold (P = 0.026) and the odds of having insulin resistance by 31.6-fold (P = 0.007), adjusted for total fat intake in women adhering to a Mediterranean eating pattern having their highest energy intake at lunch. CONCLUSIONS: Self-assessed 3-h post-lunch TG can be used to study post-prandial TG metabolism in Southern European menopausal women who are normotriglyceridaemic at fasting. Characterising an individual's post-prandial response may help menopausal women to evaluate their risk of cardiovascular disease.

Propuesta de perfil de ácidos grasos omega 3 en nutrición enteral / Proposed profile of omega 3 fatty acids in enteral nutrition

Revisamos las recomendaciones internacionales de ingesta oral de ácidos grasos n-3.y su contenido en las fórmulas de nutrición enteral. Sus acciones metabólicas dependen de su metabolización a EPA y DHA. La actividad de las 5D y 6D desaturasas, que catalizan este proceso, aumenta con el ejercicio, insulina, estrógenos de mujer fértil y proliferadores peroxisómicos, mientras que disminuye con el ayuno, déficit de proteínas y oligoelementos, edad > 30 años, sedentarismo, tabaco, alcohol, colesterol, ácidos grasos trans y saturados, insulinopenia y hormonas de estrés (adrenalina y glucocorticoides). La mayoría de las guías recomiendan 20-35% de la energía total en forma de grasas, repartidas en saturadas 7-10%, poliinsaturadas 6-10% y monoinsutaradas en España 20%. El de AG n-3 es de 0,5-2 g/día o bien 0,5-2% de la ingesta calórica total, con un límite superior de 3 g/día. El de AG n-6 es del 2,5-10% del aporte calórico total y el cociente recomendado n-6/n-3 no está bien definido pero la mayoría recomienan 5/1. El contenido en EPA y DHA, debe ser de al menos los 500 mg diarios. Por último, la ratio EPA/DHA en la mayoría es de 2/1. Las fórmulas de nutrición estándar presentan un contenido en grasas adecuado, pero la mayoría de los productos que contienen EPA y DHA exceden el límite de los 3 g/día. De los productos hiperproteicos y/o concentrados por vía oral sólo un producto de este grupo contiene EPA y DHA. Las del anciano frágil no todas aportan EPA y DHA y las que los contienen, su concentración puede ser incluso excesiva y en una relación poco parecida a la del aceite de pescado (AU)

We review the international recommendations on oral intake of n-3 fatty acids and their content in the enteral nutrition formulas. Their metabolic actions depend on their metabolization to EPA and DHA. The activity of desaturases catalyzing this process increases with exercise, insulin, estrogens in the fertile women, and peroxisomal proliferators, whereas it decreases with fasting, protein and oligoelements deficiencies, age < 30 years, sedentary lifestyle, cigarette smoking, alcohol, cholesterol, trans and saturated fatty acids, insulin deficiency, and stress hormones (adrenalin and glucocorticoids). Most of the guidelines recommend that 20-35% of the total energy comes from fat, being 7-10% saturated fats, 6-10% polyunsaturated, and 20% monounsaturated, in Spain. The recommendation for n-3 FA is 0.5-2 g/day or 0.5-2% of total caloric intake, with an upper limit of 3 g/day. For n-6 FA, 2.5-10% of total caloric intake, the n-6/n-3 ratio not being well established although most of the guidelines recommend 5:1. The EPA and DHA content should be at least 500 mg per day. Finally, the EPA/DHA ratio is 2:1 in most of them. Standard nutrition formulas present an appropriate fat content, although most of the products containing EPA and DHA exceed the limit of 3 g/day. Among the products with hyperprotein and/or concentrated, only of them contains EPA y DHA. Not all the formulas used for the frail elderly contain EPA or DHA, and in those containing them their concentration may be excessive and with a proportion very dissimilar to that of fish oil (AU)

[Proposed profile of omega 3 fatty acids in enteral nutrition]. / Propuesta de perfil de ácidos grasos omega 3 en nutrición enteral.

We review the international recommendations on oral intake of n-3 fatty acids and their content in the enteral nutrition formulas. Their metabolic actions depend on their metabolization to EPA and DHA. The activity of desaturases catalyzing this process increases with exercise, insulin, estrogens in the fertile women, and peroxisomal proliferators, whereas it decreases with fasting, protein and oligoelements deficiencies, age < 30 years, sedentary lifestyle, cigarette smoking, alcohol, cholesterol, trans and saturated fatty acids, insulin deficiency, and stress hormones (adrenalin and glucocorticoids). Most of the guidelines recommend that 20-35% of the total energy comes from fat, being 7-10% saturated fats, 6-10% polyunsaturated, and 20% monounsaturated, in Spain. The recommendation for n-3 FA is 0.5-2 g/day or 0.5-2% of total caloric intake, with an upper limit of 3 g/day. For n-6 FA, 2.5-10% of total caloric intake, the n-6/n-3 ratio not being well established although most of the guidelines recommend 5:1. The EPA and DHA content should be at least 500 mg per day. Finally, the EPA/DHA ratio is 2:1 in most of them. Standard nutrition formulas present an appropriate fat content, although most of the products containing EPA and DHA exceed the limit of 3 g/day. Among the products with hyperprotein and/or concentrated, only of them contains EPA y DHA. Not all the formulas used for the frail elderly contain EPA or DHA, and in those containing them their concentration may be excessive and with a proportion very dissimilar to that of fish oil.

Resultados a corto plazo del tratamiento con 131I en pacientes con bocio multinodular: influencia del grado de hipertiroidismo asociado y otras variables / Short-term results of treatment with 131I in patients with multinodular goiter: effect of the associated degree of hyperthyroidism and other variables

Objetivo. Evaluar la efectividad del tratamiento con radioyodo y la incidencia de hipotiroidismo posterior en pacientes con hipertiroidismo subclínico o hipertiroidismo clínico asociado a bocio multinodular (BMN). Métodos. Estudio retrospectivo de 69 pacientes consecutivos con BMN tratados con 131I, con una dosis fija ponderada de 16 mCi (592 MBq), durante el año 2008 y seguidos durante seis meses. Se clasificaron en dos grupos: hipertiroidismo subclínico e hipertiroidismo clínico. Comparamos la tasa de éxito y la incidencia de hipotiroidismo. Resultados. En el 82,09% de los pacientes se corrigió la disfunción tiroidea; entre los pacientes con hipertiroidismo clínico la proporción fue del 100% y con hipertiroidismo subclínico del 78,13% (p=0,105). La incidencia global de hipotiroidismo fue de 16,42%; 25,00% entre los que presentaban hipertiroidismo clínico y 14,55% entre los hipertiroidismos subclínicos (p=0,400). No se encontraron diferencias estadísticamente significativas al analizar los resultados según el grado de descenso de TSH en los pacientes con hipertiroidismo subclínico. Siete individuos presentaron anticuerpos antiperoxidasa tiroidea (anti-TPO) antes del tratamiento; la incidencia de hipotiroidismo fue superior en ellos (57,14% vs 11,67%; p=0,011). La prevalencia de arritmias cardiacas fue cuatro veces mayor en el grupo de hipertiroidismo clínico. El tratamiento previo con tiamazol afectó de manera positiva a los resultados. Conclusiones. Una dosis fija ponderada de 131I es altamente efectiva y segura para el control del hipertiroidismo clínico y subclínico asociado al BMN. Los pacientes con anticuerpos anti-TPO positivos parecen tener un elevado riesgo de desarrollar hipotiroidismo postyodo(AU)

Objective. To assess the effectiveness of radioactive iodine (RAI) therapy and the incidence of hypothyroidism post RAI in patients with subclinical hyperthyroidism or clinical hyperthyroidism with Multinodular Goiter (MNG). Methods. A retrospective study of 69 consecutive patients treated with 131I for MNG during the year 2008 observed for six months. All patients received a single fixed dose of 16 mCi (592 MBq) weighted by the gland size. They were categorized into two groups: subclinical hyperthyroidism or clinical hyperthyroidism. We compared the success rate and the incidence of hypothyroidism. Results. The thyroid dysfunction was corrected in 82.09% of the patients. Success rate was 100% in the clinical hyperthyroidism group and 78.13% in the subclinical hyperthyroidism group (P=0.105). The overall incidence of hypothyroidism was 16.42%; 25.00% of patients with clinical hyperthyroidism and 14.55% with subclinical hyperthyroidism developed this secondary effect (P=0.400). No statistically significant differences were found in the success rate in the incidence of hypothyroidism when the results were analyzed according to the thyrotropin decrease in patients with subclinical hyperthyroidism. Seven patients had positive anti-thyroid peroxidase antibodies (anti-TPO) before therapy. The incidence of hypothyroidism was significantly higher in them (57.14% vs 11.67%; P=0.011). Cardiac arrhythmias were four times more frequent in patients with clinical hyperthyroidism. Previous treatment with thiamazol positively affected the outcome. Conclusions. A single fixed weighted dose of 131I is highly effective and safe for the control of clinical and subclinical hyperthyroidism due to MNG. Patients with anti-TPO antibodies may have a high risk of developing post-iodine hypothyroidism(AU)

[Short-term results of treatment with 131I in patients with multinodular goiter: effect of the associated degree of hyperthyroidism and other variables]. / Resultados a corto plazo del tratamiento con 131I en pacientes con bocio multinodular: influencia del grado de hipertiroidismo asociado y otras variables.

OBJECTIVE: To assess the effectiveness of radioactive iodine (RAI) therapy and the incidence of hypothyroidism post RAI in patients with subclinical hyperthyroidism or clinical hyperthyroidism with Multinodular Goiter (MNG). METHODS: A retrospective study of 69 consecutive patients treated with (131)I for MNG during the year 2008 observed for six months. All patients received a single fixed dose of 16 mCi (592 MBq) weighted by the gland size. They were categorized into two groups: subclinical hyperthyroidism or clinical hyperthyroidism. We compared the success rate and the incidence of hypothyroidism. RESULTS: The thyroid dysfunction was corrected in 82.09% of the patients. Success rate was 100% in the clinical hyperthyroidism group and 78.13% in the subclinical hyperthyroidism group (P=0.105). The overall incidence of hypothyroidism was 16.42%; 25.00% of patients with clinical hyperthyroidism and 14.55% with subclinical hyperthyroidism developed this secondary effect (P=0.400). No statistically significant differences were found in the success rate in the incidence of hypothyroidism when the results were analyzed according to the thyrotropin decrease in patients with subclinical hyperthyroidism. Seven patients had positive anti-thyroid peroxidase antibodies (anti-TPO) before therapy. The incidence of hypothyroidism was significantly higher in them (57.14% vs 11.67%; P=0.011). Cardiac arrhythmias were four times more frequent in patients with clinical hyperthyroidism. Previous treatment with thiamazol positively affected the outcome. CONCLUSIONS: A single fixed weighted dose of (131)I is highly effective and safe for the control of clinical and subclinical hyperthyroidism due to MNG. Patients with anti-TPO antibodies may have a high risk of developing post-iodine hypothyroidism.

Accidente cerebrovascular: la nutricion como factor patogenico y preventivo. Soporte nutricional post ACV / Cerebrovascular accident: Nutrition as a pathogenic and preventive factor. Post-CVA Nutritional support

En esta revisión valoraremos el tema en cuatro fases: 1) Prevención primaria Factores de riesgo no modificables: 1) Edad, 2) Sexo, 3) Bajo peso al nacer, 4) Raza, 5) Factores genéticos. Factores de riesgo modificables: 1) Enfermedad aterosclerótica, 2) Hipertensión arterial, 3) Diabetes mellitus, 4) Dislipemia, 5) Hábito tabáquico, 6) Consumo abusivo de alcohol, 7) Actividad física, 8) Dieta y nutrición: Las sociedades científicas recomiendan la dieta DASH (fruta, vegetales, pobre en grasas totales y saturadas) para reducir la presión arterial. La dieta rica solamente en fruta y vegetales puede disminuir el riesgo de ictus. Se recomienda reducir el consumo de sodio (≤ 2,3 g 100 mmol/día) y aumentar el de potasio (≥ 4,7 g . 120 mmol/día). para reducir la presión arterial. 9) Obesidad y distribución de la grasa corporal, 10) Hiperhomocisteinemia. 2) Tratamiento de la fase aguda La incidencia de malnutrición varían entre un 7-15% al ingreso. Después del ictus el estado nutricional se deteriora, generalmente por disfagia y déficit motores que dificultan la alimentación autónoma estando ya desnutridos el 22-35%. La presencia de malnutrición en estos pacientes condiciona de forma desfavorable su pronóstico. En caso de presentar alguna dificultad para la ingesta normal y siempre que el riesgo de aspiración sea mínimo, estar. indicado realizar modificaciones en la textura de la dieta. Si el paciente presenta fatiga o saciedad precoz será útil hacer tomas de poca cantidad pero muy frecuentes. Con mucha frecuencia nos encontramos disfagia para líquidos y deberemos espesar éstos con productos de nutrición enteral como los módulos de espesante. En pacientes con un estado nutricional deficitario o que no cubren sus requerimientos nutricionales con dieta oral los suplementos de nutrición enteral son un recurso eficaz. En pacientes con disfagia persistente, las vías para la administración de nutrición enteral m.s frecuentes son la sonda nasogástrica (SNG) y la gastrostomía endoscópica percutánea (PEG). La fórmula de elección es una polimérica, normoproteica y normocalórica y con fibra, salvo que alguna otra situación haga recomendable otro tipo diferente. En los casos de pacientes con desnutrición al ingreso o con úlceras de decúbito se recomienda una fórmula hiperprotéica. Es frecuente la hiperglucemia de estrés, que con fórmulas específicas para la diabetes mellitus se consigue controlar sin requerir tratamiento farmacológico hipoglucemiante ni control glucémico intensivo. 3) Cuidados tras el alta El desarrollo de malnutrición en este grupo de pacientes puede ser muy frecuente y se debe a míltiples factores. Si aparece disfagia, se favorece el desarrollo de infecciones por aspiración. Se debe realizar un seguimiento nutricional de los pacientes que han requerido soporte nutricional durante la fase aguda del ictus hasta su completa recuperación y un aporte de nutrientes adecuado. La nutrición enteral domiciliaria ha demostrado ser coste efectiva en este grupo de pacientes. 4) Prevención secundaria. Manejo óptimo de los factores de riesgo vascular: 1) Hipertensión arterial, 2) Diabetes mellitus, 3) Dislipemia, 4) Hábito tabáquico, 5) Sobrepeso, 6) Vitaminas (AU)

In this review we will approach the topic in four stages: 1) Primary prevention Non-modifiable risk factors: 1) Age, 2) Gender, 3) Low birth weight, 4) Ethnicity, 5) Genetic factors. Modifiable risk factors: 1) Atherosclerotic disease, 2) Arterial hypertension, 3) Diabetes mellitus, 4) Dyslipidemia, 5) Cigarette smoking, 6) Alcohol abuse, 7) Physical activity, 8) Diet and nutrition: the scientific societies recommend the DASH diet (fruits, vegetables, and low in total fat and saturated fat) in order to reduce the blood pressure. The diet rich only in fruits and vegetables may decrease the risk of ictus. Reduction in sodium intake (£ 2.3 g or 100 mmol/day) and increase of potassium (4.7 g or 120 mmol/day) are recommended to reduce arterial blood pressure. 9) Obesity and distribution of body fat, 10) Hyperhomocysteinemia. 2) Managing the acute phase The incidence of malnourishment ranges 7%-15% at admission. After the CVA the nutritional status worsens, generally due to dysphagia and motor deficits that impair autonomous feeding, 22%-35% of the patients being already malnourished. The presence of malnourishment in these patients unfavourably affects their prognosis. In the case of having some difficulty for normal feeding and whenever the risk for aspiration is low, modifying the texture of the diet is indicated. If the patient presents fatigue or early satiety, having small but frequent intakes will be useful. It is common to encounter dysphagia for liquids so that beverages should be thicken with enteral nutrition products such as thickeners. In patients with a deficient nutritional status or not meeting the nutritional requirements with an oral diet, the enteral nutrition supplements are an effective resource. In patients with persistent dysphagia, the most common routes for administrating enteral nutrition are the nasogastric tube (NGT) and percutaneous endoscopic gastrostomy (PEG). The first choice formula should be polymeric, normo-proteinic and normocaloric, with fibre, unless the recommendation is changed by some other condition. In the case of patients with hyponutrition at admission or with decubitus ulcers a hyperproteinic diet is recommended. Stress-induced hyperglycaemia is common, which may be controlled with specific diabetes mellitus formulas without needing pharmacological therapy for lowering glucose levels or intensive glycemic monitoring. 3) Care at discharge The development of malnourishment in this group of patients may be very common and is due to multiple factors. If dysphagia ensues, the occurrence of aspiration induced infections is facilitated. A nutritional follow-up should be done in the patients having required nutritional support during the acute phase of a CVA until complete recovery and appropriate nutrients intake are achieved. Home-based enteral nutrition has been shown to be cost effective in this group of patients. 4) Secondary prevention. Optimal management of vascular risk factors: 1) Arterial hypertension, 2) Diabetes mellitus, 3) Dyslipidemia, 4) Cigarette smoking, 5) Overweight, 6) Vitamins (AU)

Insulinización en el paciente diabético en tratamiento con nutrición enteral y parenteral / Insulin therapy in the diabetic patient receiving enteral or parenteral nutrition

La nutrición enteral o parenteral en pacientes con diabetes es frecuente en la práctica clínica. La valoración nutricional, las indicaciones del soporte nutricional y el cálculo de los requerimientos calóricos son similares a los de los pacientes no diabéticos, a excepción de las situaciones clínicas de gastroparesia diabética y de sobrepeso. Se debe evitar la sobrealimentación, por lo que el peso usado para calcular los requerimientos calóricos debería ser uno intermedio entre el ideal y el real. Las fórmulas de nutrición enteral con menor contenido en hidratos de carbono y más ricas en grasas se asocian con un mejor control glucémico que las fórmulas estándares usadas. No hay evidencias científi cas para la nutrición enteral continua en pacientes hospitalizados. Cuando se inicia nutrición enteral por sonda, se recomienda el uso de insulinas de acción rápida hasta que la perfusión llega a 40 mL/h, a partir de la cual el empleo de insulina NPH o análogos de insulina de acción prolongada (glargina o detemir) suele ser seguro. Se pueden usar hipoglucemiantes orales en pacientes diabéticos tipo 2 bien controlados y estables. Antes de la administración de nutrición parenteral, debería realizarse un control de glucemia y añadir una cantidad basal de insulina rápida a la solución de nutrición parenteral en los casos de glucemia >150 mg/dL o en pacientes en tratamiento previo con insulina o hipoglucemiantes orales. Se suele iniciar con 0,1 UI/g de glucosa administradas en la solución y suplementos de insulina rápida subcutánea ante situaciones de hiperglucemia, pero cuando ésta es importante, se requiere la instauración de perfusión de insulina intravenosa (i.v.)

In clinical practice, enteral or parenteral nutrition is frequently administered to diabetic patients. Nutritional assessment, indications for nutritional support and the estimation of nutritional needs are similar to those of nondiabetic patients, except that diabetic gastroparesis and excess weight are specific clinical conditions associated with diabetes. To avoid overfeeding, the weight used to estimate caloric requirements should be intermediate between the ideal and the current weight. Enteral formulas with less carbohydrate and more fat content are associated with better glycemic control than standard formulas. There is no evidence to support continuous enteral feeding in hospitalized patients. When initiating tube feeding, the administration of short-acting insulin is recommended, but once the infusion rate has reached 40 mL/h, the use of NPH or long-acting insulin analogues (insulin glargine or detemir) is generally safe. Oral hypoglycemic agents can be used in well-controlled type 2 diabetic patients. Before initiation of parenteral nutrition, capillary blood glucose should be measured. If glucose values are higher than 150 mg/dL or the patient had previously been treated with insulin or oral hypoglycemic agents, the addition of short-acting insulin to the parenteral nutrition solution is recommended. A common starting dose is 0.1 IU/g of dextrose in the solution and subcutaneous short-acting insulin supplements for elevated glucose values. When hyperglycemia is marked and persistent, intravenous insulin infusion is required

[Evaluation of food intake in hemodialysis using a food consumption and appetite questionnaire]. / Valoración de la ingesta en hemodiálisis mediante un cuestionario de consumo alimentario y apetito.

Protein calorie malnutrition is a common complication in chronic hemodialysis patients (CHP). Although many factors could promote malnutrition, inadequate nutrient intake seems to be one of the most important. An Appetite and Diet Assessment Questionnaire (ADAQ) was developed, and we have performed a cross-sectional study in 44 CHP to investigate its capacity to predict an inadequate intake. Dietary evaluation was based on a diet diary-assisted recalls (DDAR). On the other hand, the validity of PCR and the differences in the DDAR and ADAQ between the days of dialysis and the days without dialysis were studied. The predictive value of inadequate intake of the ADAQ and the PCR were analysed with the ROC curve. The protein intake was 1.3 +/- 0.3 g/kg/day and the energy intake 29.2 +/- 0.6 kcal/kg/day. The average PCR was 1.14 +/- 0.3. The ROC curve to predict inadequate intake from the ADAQ shows an area under the curve of 0.84 for the protein intake and 0.73 for the energy intake. A cut-off ponit of 18 gives a sensitivity of 100% and a specificity of 44% for the detection of poor protein intake (< 1.2 g/kg/day) and of 74% and 56% for the detection of poor energy intake (< 30 kcal/kg/day). The ROC curve to predict inadequate protein intake from the PCR obtains an area under the curve of 0.81. The cut-off 1.06 gives the best sensitivity (100%) and specificity (64%) for the detection of insufficient protein intake. We did not find any significant difference in the DDAR or in the ADAQ between the days of dialysis and the days without dialysis. Despite the subjective interpretation, the relationship between ADAQ and protein-energy intakes analysed by DDAR was highly significant. The questionnaire is simple and can therefore be used as a screening rest to detect and correct alterations in the diet which could otherwise lead to malnutrition. The determination of PCR gives a good sensitivity and specificity for the detection of poor protein intake, although the results are modified in anabolic or catabolic states which can clinically go undetected. We do not register differences in diet between the days of dialysis and the days without dialysis.

Valoración de la ingesta en hemodiálisis mediante un cuestionario de consumo alimentario y apetito / Evaluation of nutrient intake in hemodialysis patients validity of an appetite and diet assessment and of protein catabolic rate determination

Dentro del origen multifactorial de la malnutrición en hemodiálisis periódica (HDP) la ingesta inadecuada es una causa importante, valorándose habitualmente mediante registro de consumo alimentario (RCA). Con el objetivo de detectar de forma sencilla y rápida una pobre ingesta, se desarrolla un Cuestionario de Consumo Alimentario y Apetito (CCAA) y se estima su capacidad para predecir un aporte proteico-calórico inadecuado, tomando como patrón de referencia el RCA. Así mismo se analiza la capacidad predictiva de insuficiente ingesta proteica que ofrece la tasa de catabolismo proteico (PCR) y se estudia si existen diferencias en los valores del RCA y del CCAA entre los días de diálisis y los días sin diálisis. Se incluyen en el estudio 44 pacientes en HDP en situación clínica estable. Para la evaluación de la ingesta se utilizó el método de RCA mixto (mediante pesada y entrevista) de dos días (uno de diálisis y uno de no diálisis). Se determinó el PCR y se desarrolló el CCAA, un cuestionario de 34 ítems acerca de la adecuación de la dieta y el nivel de apetito. Se realiza una baremación del CCAA y se constrastan estos datos y los valores del PCR con el RCA mediante el análisis de curva ROC. La ingesta proteica media fue de 1,3 ñ 0,3 g/kg/día y la calórica de 29,2 ñ 6 kcal/kg/día según RCA. El PCR medio fue de 1,14 ñ 0,3. Al relacionar el CCAA con el RCA obtenemos un área bajo curva de 0,84 (IC 0,70-0,93) para la ingesta proteica y de 0,73 (IC 0,57-0,85) para la calórica. El punto de corte en 18 ofrece unos valores de sensibilidad del 100 por ciento y especificidad del 44 por ciento para la detección de pobre ingesta proteica (< 1,2 g/kg/día) y del 74 por ciento y 56 por ciento para la detección de pobre ingesta calórica (< 30 kcal/kg/día). Al relacionar el PCR con la ingesta proteica según RCA obtenemos un área bajo curva de 0,81 (IC 0,660,91). El puto de corte en 1,06 nos ofrece la mejor sensibilidad (100 por ciento) y especificidad (64 por ciento) en la detección de ingesta proteica insuficiente. No encontramos diferencias significativas entre los días de diálisis y los días sin diálisis en el RCA ni en el CCAA. Consideramos que el CCAA, a pesar de la subjetividad de su interpretación, se correlaciona bien con la ingesta alimentaria analizada mediante RCA. Su realización es sencilla, por lo que puede utilizarse de forma repetitiva como screening para detectar y corregir de forma precoz alteraciones en la ingesta alimentaria que pueden conducir a déficits nutricionales. La determinación del PCR presenta una buena sensibilidad y especificidad en la detección de pobre ingesta proteica, aunque sus resultados se alteran ante estados anabólicos o catabólicos que clínicamente pueden pasar desapercibidos. No registramos diferencias en la dieta entre los días de diálisis y los días sin diálisis (AU)

Diagnóstico diferencial de las hipoglucemias / Differential diagnosis of hypoglucemia

No disponible

[Diabetes and nutrition]. / Diabetes y nutrición.

Diabetes mellitus is one of the most frequent metabolic syndromes found in our hospitals, occurring at around 10%. There are basically two types: the most common is Type 2, associated with obesity in almost 80% of cases and family groupings, and then, far behind, comes Type 1 which requires insulin administration for life. Furthermore, there is a condition known as "stress hyperglycaemia" in which a patient without a prior history of diabetes mellitus responds to stress with a syndrome comprising hypermetabolism, hyperglycaemia, hyperlactacidaemia and protein catabolism. The desirable pre-prandial levels of glycaemia in an outpatient are between 80 and 120 mg/dl (under 100 mg/dl is normal) and between 100 and 140 mg/dl before retiring (levels of 110 mg/dl are normal). In patients with artificial nutrition, whether parenteral or enteral, the control of glycaemia is not so strict and the recommendation is for a level of around 150-200 mg/dl in the acute stress phases, falling to 100-150 mg/dl in stable patients. The ideal enteral formula for diabetic patients has been a bone of contention for years and has still not been satisfactorily resolved. The discussion centres on the replacement of saturated fatty acids by mono-unsaturated fatty acids (MUFA) or by carbohydrates. The studies of patients undergoing prolonged treatments with MUFA-rich enteral diets have shown a greater control of glycaemia with these diets than with those rich in carbohydrates, so Type 2 diabetics and in stress hyperglycaemia with enteral nutrition, there is an ever stronger proposal to use MUFA rich formulas, whereas in Type 1 diabetics and in Type 2 patients with high prior requirements of insulin, it would be more recommendable to use diets with a more intermediate composition. With regard to parenteral nutrition, there is a consensus on increasing the amount of fatty acids to the detriment of carbohydrates, but the use of carbohydrates other than glucose is not so clear. The use of fast-acting insulin, either intravenously or subcutaneously, is recommended in the acute stages of the underlying condition because any instability in the patient makes it difficult to plan the required dose of intermediate-acting NPH insulin. The use of metformin or acarbose is not recommended. In parenteral nutrition, the subcutaneous administration of NPH insulin is often required at doses of 30% of the home dosage as the basal insulin therapy in addition to fast-acting insulin in the nutrition bag and a regimen of subcutaneous fast-acting insulin every 6 hours depending on glycaemia.

[Leptin in the endocrinology of obesity]. / Leptina en la endocrinología de la obesidad.

The article summarizes the endocrinology axis in relation to leptin in the obesity. There is a glucocorticoid hypothesis in the obesity origin. Human plasma leptin levels are elevated in Cushing's syndrome and there is a robust leptin secretory responses to dexamethasone. Obesity impacts on reproductive function in man and women. Leptin levels are higher in women than in men and a critical blood leptin level is necessary to trigger reproductive ability in women. The relationship between body mass index and circulating leptin varies during the course of spontaneous cycles in women, the best correlation occurring during the luteal phase when progesterone and leptin concentrations are highest. Obesity is associated with a decrease in growth hormone (GH) and reversible with weight loss. The influence of body composition on GH secretion in the obesity may be mediated through leptin, acting as a peripheral signal from adipose tissue. Thyroid dysfunction appear not associated with alterations in serum leptin levels. There is a significant relationship between insulin and leptin, but it is not immediate, since type 2 diabetics show similar leptin levels to those of nondiabetic humans of the same body mass index.

Leptina en la endocrinología de la obesidad / Leptin in the endocrinology of obesity

El artículo revisa los diferentes ejes endocrinológicos en relación con los niveles plasmáticos de leptina del paciente obeso. Existe una hipótesis glucocorticoidea como causa de obesidad. Los niveles plasmáticos en humanos de leptina están elevados en el síndrome de Cushing y hay una respuesta secretora franca de leptina a la dexametasona. La obesidad altera la función reproductora tanto en el hombre como en la mujer. Los niveles de leptina son mayores en la mujer que en el hombre y se requiere un nivel crítico de leptina en plasma para desarrollar la capacidad reproductora femenina. La interrelación entre el índice de masa corporal y los niveles circulantes de leptina varían en el curso de los ciclos ováricos, la mejor correlación aparece en la fase luteal, cuando los niveles de leptina y progesterona están mas altos. La obesidad se asocia a disminución de los niveles plasmáticos de GH, situación que revierte con la pérdida de peso. La infuliencia de la composición corporal sobre la secreción de GH en la obesidad puede estar relacionada con la leptina, que acutaría como una señal periférica del tejido adiposo. La disfución tiroidea no parece producir alteraciones en los niveles de leptina. Existe una interrelación significativa entre los niveles de insulina y leptina, pero ésta no está clara ya que en el paciente con diabetes tipo 2 encontramos niveles similares de leptina a los de los controles con similar indice de masa corporal (AU)

High-fat versus high-carbohydrate enteral formulae: effect on blood glucose, C-peptide, and ketones in patients with type 2 diabetes treated with insulin or sulfonylurea.

Recently, two commercial enteral formulae for diabetic patients have been made available in Spain: a high-complex-carbohydrate, low-fat formulation (HCF) and a low-carbohydrate formulation (RCF). This study compares the effects of the two enteral nutritional formulae in patients with non-insulin-dependent diabetes mellitus (type 2 diabetes) treated with sulfonylurea or insulin. Fifty-two type 2 diabetes patients were randomly assigned to receive one of the two enteral formulae. Test enteral formula breakfast (250 cc) were consumed at approximately 0900 h after routine medications (insulin or oral agents) had been taken. Venous blood samples were obtained during fasting, before medication, and at 30 and 120 min after the start of the meal. The glycemic response of patients to the HCF was significantly greater than to RCF, but lower than in the sulfonyl type 2 diabetes treated groups. The incremental glucose response was within acceptable levels except in insulin treatment type 2 diabetes patients given HCF. Glucose, insulin, and C-peptide responses were higher in HCF than RCF groups. Two-factor analysis of variance on mean increments of blood glucose and C-peptide from basal levels to 30 min show the type of enteral nutrition as the main factor (P = 0.0010 and P = 0.0005, respectively). The RCF formula supplies 50.0% of energy as fat and 33.3% as carbohydrates, so it may be a ketogenic diet. It was found that both ketone bodies were higher after RCF than after HCF ingestion, but without statistical significance. We conclude that the partial replacement of complex digestible carbohydrates with monounsaturated fatty acids in the enteral formulae for supplementation of oral diet may improve glycemic control in patients with type 2 diabetes. The long-term effects of enteral diets high in monounsaturated fatty acids need further evaluation in patients with type 2 diabetes.

[Diabetes in hemodialysis: study of differential factors]. / Diabetes en hemodiálisis: estudio de factores diferenciales.

OBJECTIVES: In uremic patients with diabetes mellitus, morbi-mortality on maintenance hemodialysis is considerably higher than in nondiabetic patients. This is mainly due to age, seniority and quality of the hemodialysis therapy, nutritional status, plasmatic lipid levels and associated pathology. We compare all these factors in the uremic patients under hemodialysis in diabetics and non-diabetics. METHODS: We have studied 307 uremic patients under hemodialysis therapy during 199 and 1996. Sixty of them had been diagnosticated of diabetes mellitus (19.6%), 17 were type I (DM-I) and 27 were type II (DM-II). We selected two control groups no-diabetics, one for each subgroup of diabetics with similar characteristics in age, sex and hemodialysis seniority. The control group for DM-I were 34 patients and for DM-II were 54 patients. RESULTS: Ideal body weight percentage, body mass index, mid-arm muscle circumference percentil, serum albumin and prealbumin are subnormal for DM-I. By considering whole nutritional date, a moderate to severe malnutrition was observed in 79% of DM-I patients, 50.4% of all non diabetics and only in 30.6% of patients included in the DM-II group. However, DM-II patients present hypertrigliceridemia and a decrease in HDL cholesterol and apolipoprotein A levels with a high atherogenic index. Significantly higher rates of associated pathology were observed among both types of diabetic patients than their control groups and especially referred to cardiovascular and neurological diseases. CONCLUSIONS: In conclusion, diabetes mellitus is an increasing incidence pathology in hemodialysis programs, that is associated to a higher morbi-mortality because vascular disease. Undernutrition is the main factor in DM-II whereas hyperlipidemia is in DM-II.

[Predictive value of serum ferritin in the prognosis of acute cerebrovascular accident]. / Valor predictivo de la ferritina sérica en el pronóstico del accidente cerebrovascular agudo.

INTRODUCTION: Recent studies show that a raised level of serum ferritin indicates a poor prognosis in CVA patients, as do the well-known hyperglycemia, dyslipemia and arterial hypertension. The evolution and prognosis of acute cerebrovascular accidents are determined by a series of factors, some of which can be modified. This leads to a search for factors which can be modified and therefore influence the course of the illness. OBJECTIVE: To determine the ferritin levels and other parameters during the course of the illness of patients with serious cerebral vascular pathology and evaluate their effect on prognosis. MATERIAL AND METHODS: A prospective study was carried out on patients diagnosed as having CVA, admitted to the Neurology Department of the Miguel Servet Hospital (Zaragoza) during 1994, and who were in neurological coma (Glasgow scale less than 7) during the first 24 hours, and unable to swallow. The levels of various plasma parameters were determined (glucose, cholesterol, ferritin, etc.) on admission and then every 10 days. CONCLUSIONS: Plasma ferritin levels higher than those considered normal by the laboratory, in the first few hours after CVA, are an independent predictive factor suggesting unfavourable evolution of the vascular condition. Equally, raised ferritinemia in the first weeks after CVA indicates a worse prognosis. This laboratory test may be carried out on patients with acute CVA to obtain more information on which to base the prognosis.

[Rate of protein catabolism as an indicator of protein ingestion in uremic patients on hemodialysis]. / Tasa de catabolismo proteico como indicador de la ingesta proteica en pacientes urémicos en hemodiálisis.

Protein catabolic rate (PCR) has been proposed as a indirect index of dietary protein intake, but its sensitivity has been discussed. In a group of 140 chronic uremic patients undergoing maintenance hemodialysis, we evaluated the nutritional status (body mas index: BMI, triceps skinfold thickness: TST, arm muscle circumference: AMC, serum total proteins, albumin and lymphocytes) and its relation with dietary survey and PCR levels. PCR was correlated positively with Kt/V (p: 0.0001, r: 0.45) and with seric albumin (p: 0.01, r: 0.22), whereas dietary protein intake by dietary survey (g/Prot/Kg/day) was correlated strongly with anthropometric measurements like BMI, AMC (p: 0.0001) and less with Kt/V (p: 0.01), but not with serum albumin. PCR was correlated with dietary survey results: g Prot/Kg/day (p: 0.04, r: 0.18) and Kcal/Kg/day (p: 0.03, r:0.2). The results suggest that nutritional parameters with slow evolution as anthropometric measurements could be related with usual dietary intake (dietary survey), whereas serum albumin (that vary early with recent changes of dietary intake) could be related better with a biochemical index like PCR, in these way both determinations are complementary.