Usual Body Weight Research Articles

Tolerance and acceptability of a new oral nutritional supplement in cystic fibrosis

It has been shown that nutrient deficiencies which are secondary to malabsorption and pulmonary disease in cystic fibrosis (CF) can be treated effectively with oral nutritional supplements, but inconvenience and taste aversion present obstacles to success. The Cystic Fibrosis Foundation has supported the development of an oral nutritional supplement, Calories Plus™, a product specifically formulated to provide 450 calories, 25 g fat, 13 g linoleic acid, 2500 IU vitamin A, and 15 IU vitamin E per serving reconstituted in water. We tested tolerance and acceptability, and evaluated the effect of the supplement on short-term nutritional status and dietary intake in patients with CF. Subjects were their own controls for this 3-month study and were recruited during regular visits to the University of Wisconsin Hospital and Clinics in Madison, Wisconsin. Patients ≥ 4 yr were selected if they met one of the following criteria: weight < 89% reference weight, weight loss > 5% usual body weight, decrease of 1 growth channel in weight-for-age or weight-for-height, a plateau in weight gain for ≥ 3 months, or adequate growth/weight maintenance reliant upon the use of another nutritional supplement. All subjects were receiving pancreatic enzyme therapy and were not participating in other research protocols. Of the 23 subjects enrolled, 19 completed the study (8 over 18 yr; 11 under 18 yr). Subjects consumed Calories Plus™ at a maximum of 30% their estimated daily energy requirements. Tolerance and acceptability questionnaires and 3-day food records were completed monthly. Anthropometric measurements and plasma levels of retinol, α-tocopherol, and serum albumin were obtained at 0 and 3 months. Data were analyzed using Minitab and Statistical Analysis Software (SAS). A significance level of 0.05 was used for all tests. Of the 16 who had previously used oral nutritional supplements, 9 preferred the taste of Calories Plus™. Mean compliance was 70% of recommended intake. All subjects tolerated Calories Plus™ although 12 reported mild symptoms of fullness, nausea, and/or bloating which were resolved upon distributing intake throughout the day. Difficulty in reconstitution was the most commonly reported problem. There were no significant changes in plasma retinol, α-tocopherol, and serum albumin. Normal food intake was not significantly suppressed. Linoleic acid intake increased significantly (p = 0.0003). Weight also increased significantly (p = 0.01). We conclude that Calories Plus™ would be a beneficial addition to the supplementation choices available to patients with CF. This study was supported by a grant from the Cystic Fibrosis Foundation.

The relationship between nutritional status and opportunistic infections in HIV+/ARC/AIDS patients at a VA hospital

The protein energy malnutrition manifested by patients with HIV infection may lead to further depression of their immunological function. The objectives of this study were to examine the relationship between the nutritional status and the incidence of opportunistic infections; and to determine the differences in nutritional status of HIV+/ARC/AIDS patients with and without active infections. A retrospective review of medical charts of 97 veterans with diagnoses of HIV+/ARC/AIDS who were participants in an outpatient Infectious Disease Clinic at Hines VAH was conducted from June 1990 to January 1992. Data obtained were age, sex, usual body weight, current weight, height, initial and current serum albumin, total and current opportunistic infections, HIV risk factors and nutrition intervention provided. Data analysis was completed by utilizing the student's t-test and chi square analysis. Mean age of all subjects was 41 (range 29–61). Sixty-six percent were drug abusers, 21% homosexuals, 2% drug abusers and homosexuals, with 2% unknown. Chi square analysis demonstrated a significant relationship between increasing opportunistic infections per month and declining serum albumin x2 (4, n=97) = 26.104, p<.001 and opportunistic infections/month and progressive weight loss from usual body wt x2 (4, n=97) = 32.029, p<.001. The mean percent weight loss from usual body weight of subjects without active opportunistic infections was 3.5%, while those with active opportunistic infections was 15.2%. The difference in weight loss between the two groups was statistically significant (p<.001). The mean serum albumin of subjects without active opportunistic infections was 3.89 g/dl while the mean serum albumin of those with active opportunistic infections was 2.74 g/dl. The difference between these two values was statistically significant (p<.001). Thirty five percent of the subjects had received nutrition counseling, while 28% had some type of nutrition support (oral supplements, enteral/parenteral). These findings suggest that nutrition support to prevent the decline of nutritional status of these patients would be beneficial. This may avert the development of opportunistic infections by maintaining optimal immune function.

Prevalence of malnutrition in the institutionalized elderly residents

Despite the wide spread recognition that nutrition plays a vitally important role in the establishment and maintenance of an optimal level of a patients' health, little attention has been devoted to the study of the nutritional status of the elderly residing in nursing home. This study reports the prevalence of malnutrition among 1300 long-term care residents. The surveys were conducted during the period January 92 to January 93, and included 12 long-term care facilities. Residents with the advanced diseases and terminal illnessess were excluded from this study. Factors evaluated include rate of weight loss, diagnosis, food intake, and hematological values. Twelve percent of residents (155) had experienced a severe weight loss, none had an appropriate dietary/nursing intervention. Out of 155 residents, 57% lost 11.50± 4% of their usual body weight within three months, and 43% lost 16± 5% within six months. Hematological tests were obtained from 50% (75) of sample residents. Mean serum values were: Albumin, 3.1±.3; hemoglobin, 11.4±.6 (men); hemoglobin, 10.6±.5 (women); hematocrit, 35±4 (men); hematocrit, 34.±3 (women). Food intake was evaluated by visual observation at meal time during study period (2 to 3 days at each nursing home). The mean percentage of food intake for sample residents (155) was 30% of meal served (range from 0–50%). Illness/conditions reported frequently included hypertension, diabetes, dementia, cardiovascular diseases, and osteoporosis. Because the rate of weight loss plays a key role in the nutritional status of elderly people, the evaluation of this factor should prompt adequate dietary and nursing intervention. Decline in hemoglobin and hematocrit and concomitant increased anemia with age is not necessarily a result of normal aging, thus the detection of anemia in elderly person should also prompt appropriate clinical attention.

Nutritionally-induced changes in parasympathetic function

It is possible to quantify the input of the parasympathetic nervous system to heart rate variability in man by the spectral analysis of heart rate variability. This is done by noninvasive, computerized electrocardiography over several minutes of observation. Earlier studies from this laboratory demonstrated that when body weight of obese or nonobese subjects is increased 10% or decreased below usual body weight, there are accompanying changes in autonomic function, as measured by alterations in heart rate variability. The clearest of these changes is an abrupt decline in parasympathetic function with increase in body weight, and an increase in parasympathetic activity as body weight declines, and when new, lower body weights are maintained. Recently, it has been possible to examine this phenomenon by a pharmacologie dissection of the autonomic input to heart rate variability. The separate input of each branch of the nervous system to cardiac variability, as well as the intrinsic heart rate, is measured by this approach. The subjects studied to date have been few, but there is confirmation of a major change in parasympathetic function with weight alteration whereas sympathetic changes are small.

Protein-energy undernutrition and the risk of mortality within 1 y of hospital discharge in a select population of geriatric rehabilitation patients

To determine whether undernourished elderly patients are at increased risk for mortality, independent of nonnutritional factors affecting outcomes, 109 patients were evaluated at admission to a geriatric rehabilitation unit (GRU) and then followed prospectively for 1 y after hospital discharge. During the interval of observation, 33 (30%) patients died, 11 before hospital discharge and 22 within the year subsequent to discharge. Of the 81 nutritional and nonnutritional variables analyzed, the best predictor of mortality, as determined by stepwise-discriminant-function analysis, within 1 y of hospital discharge was the percent of usual body weight lost in the year previous to admission, followed by the subscapular skinfold thickness and the discharge Katz Index of Activities of Daily Living (ADL) score. Percent of weight lost was also the strongest predictor of 1-y post-GRU-admission mortality. These results provide compelling evidence for the importance of nutritional status in predicting both in-hospital and postdischarge mortality in a population of frail, male GRU patients.

Muromonab CD-3: a review of its pharmacology, pharmacokinetics, and clinical use in transplantation.

Muromonab CD-3 (OKT-3) is a monoclonal antibody that is highly effective in the treatment of acute rejection in solid organ transplants. Due to its monoclonal nature, each molecule is identical because it is derived from a single antibody-producing clone. OKT-3 is administered only by intravenous injection and has a harmonic half-life of approximately 18 hours. It binds specifically to the CD-3 complex, which is involved in antigen recognition and cell stimulation, on the surface of T lymphocytes. Immediately after administration CD-3-positive T lymphocytes are abruptly removed from the circulation. The route of metabolism for OKT-3 is not clear; it may be removed by opsonization by the reticuloendothelial system when bound to T lymphocytes, or by human antimurine antibody production. The agent has been effective in reversing corticosteroid-resistant acute rejection in renal, liver, and cardiac transplant recipients. Its use in pancreatic and bone marrow recipients is inconclusive. OKT-3 has a considerable number of initial side effects, and some life-threatening reactions may occur. This drug should not be administered to any patient who is greater than 3% usual body weight because of the potential for the development of severe pulmonary edema. OKT-3 may also be associated with a high rate of infection, especially of the viral type. The usual dose is 5 mg administered as an intravenous bolus over 2-4 minutes daily for 10-14 days. Approximately 85% of patients treated with OKT-3 develop reactive human antimurine antibodies that, over time, may lead to tachyphylaxis and neutralization of the murine antibody OKT-3. OKT-3 is potent immunosuppressive agent and is an important prototype of future monoclonal antibodies.

Symptoms potentially influencing weight loss in a cancer population. Correlations with primary site, nutritional status, and chemotherapy administration

A nutritional assessment including determination of symptoms potentially influencing weight loss was prospectively performed on 254 consecutive cancer patients with favorable performance scores (Eastern Cooperative Oncology Group [ECOG] level 0 to 2). Primary cancer sites included the following: non-small cell lung (n = 93), colon (n = 50), prostate (n = 23), oropharyngeal (n = 18), breast (n = 15), gastrointestinal (n = 13), and other (n = 42). Thirty-nine percent of patients had received no prior chemotherapy or radiation therapy. Common symptoms in the population were abdominal fullness (61%), taste change (46%), constipation (41%), mouth dryness (40%), nausea (39%), and vomiting (27%). Current caloric intake was surprisingly similar in 170 patients with weight loss (percent usual body weight [PUBW], less than or equal to 95%) compared with 84 without weight loss (PUBW, greater than 95%; 31.4 +/- 1.5 versus 30.5 +/- 2.1 kcal/kg/d, respectively). Symptoms identified by multivariate analysis as occurring significantly more frequently in populations with weight loss included abdominal fullness (P less than 0.001), taste change (P less than 0.002), vomiting (P less than 0.005), and mouth dryness (P less than 0.02). There was no difference in frequency of symptoms between patients with or without prior chemotherapy. These results indicate that gastrointestinal/oral symptoms potentially influencing weight loss are prevalent early in the course of cancer patients with unresectable disease, regardless of current nutritional status, caloric intake, or prior therapy experience.

Prognostic role of preoperative nutritional and immunological assessment in the surgical patient.

The utilization of delayed hypersensitivity response (DHR) for the identification of high-risk patients with regard to postoperative septic complications is still discussed. The aim of this study was to clarify how much DHR may improve the prognostic capacity of nutritional assessment (NA). Nutritional and immunological evaluations were performed at admission on 405 patients undergoing elective general surgical procedures. Subjects with serum albumin less than or equal to 3.0 g/dl or total iron-binding capacity less than or equal to 220 micrograms/dl or weight loss greater than or equal to 10% with respect to usual body weight were classified as malnourished. DHR was assessed by performing skin tests with four recall antigens: PPD, candida, trichophyton, sk-sd. The incidence of postoperative complications resulted higher among the 187 malnourished patients (31.0%) than in the 218 well-nourished ones (14.2%) (p less than 0.001), and among the 213 anergic patients (29.6%) than in the 192 normal responders (13.5%) (p less than 0.001). To determine how much skin tests may improve the prognostic ability of NA, the relationship between DHR and postoperative complications was also studied in the malnourished and in the well-nourished patients, separately. In the malnourished group, the patients with an impairment of DHR had a higher incidence of postoperative infections than normal responders (p less than 0.05). In the well-nourished group, no significant differences were found between anergic patients and normal responders. In our study, DHR slightly improved the prognostic capacity of NA. Therefore, the first approach to identify the high-risk patients seems to be the unexpensive, quick and available determination of nutritional status.

Body size and survival in premenopausal breast cancer.

The survival experience of 582 women with premenopausal breast cancer was examined to determine whether prognosis was related to body size or to demographic and reproductive factors. During the follow-up period 228 patients died and 18 emigrated or were lost to follow-up. Usual body weight, reported at the time of diagnosis, was a strong predictor of survival, with a statistically significant trend towards lower survival with increasing weight. Height and obesity (Quetelet index) were not significantly related to survival, although the tallest women and the most obese women appeared to fare worst. Other characteristics of prognostic importance were disease stage and reproductive history (women who were older when their first child was born fared better). Women aged 46-50 when diagnosed also appeared more likely to survive but no clear trend with age was evident. Other characteristics of the women including social class, cigarette use and oral contraceptive use were not significantly related to survival probability.

The value of nutritional assessment in the surgical patient.

The prevalence of malnutrition in Veterans Administration Hospitals has been well documented. Several methods have been proposed to assess nutritional status including prognostic nutritional index (PNI) and instant nutritional assessment (INA). A prospective study was done to evaluate the currently used nutritional assessments and determine their efficacy based on sensitivity and specificity in predicting surgical morbidity and mortality. Data on 46 patients were evaluated for the multiparameter index of PNI, total lymphocyte count and serum albumin for INA, and weight loss alone. In this analysis, intermediate and high risk PNI were combined as positive predictor of complications. Any abnormal value in INA was considered positive as was weight loss of greater than 6% of usual body weight. Sensitivity and specificity of each assessment method were determined by 2 X 2 contingency table, and significance of observed differences between methods was determined by chi 2 analysis. There were no complications or deaths in patients with less than 6% weight loss. All three patients with abnormal albumin and total lymphocyte count had complications as compared to only three of 32 patients when both of these parameters were normal. The PNI was also able to predict complications with an increasing incidence as the PNI increased. Only the difference between specificity of weight loss alone vs INA was statistically significant, p less than 0.05. Thus, weight loss alone can be used as a rapid, inexpensive assessment of nutritional status for predicting postoperative complications.

Metabolic abnormalities in the cancer patient.

Many malnourished patients with cancer fail to gain weight with what appears to be adequate nutritional support. Metabolic abnormalities resulting from remote effects of the tumor on host metabolism have been postulated to increase energy requirements in such cancer patients. In the current study, 44 patients with lung cancer who had significant weight loss (16 +/- 2% of usual body weight) were studied under metabolic ward conditions. Whole body glucose production rates were significantly elevated in cancer patients compared to age-matched healthy controls. Blood glucose levels 2 hours after a standard oral glucose challenge were also significantly increased, but insulin levels were not different at this time. Fasting glucose and insulin levels were not different. Fasting plasma alanine levels were significantly decreased in these patients, while branched-chain amino acids were not different. Increased alanine flux for gluconeogenesis is likely to reflect a basic metabolic abnormality in patients with cancer and could be explained on the basis of a resistance to insulin action in such patients.

Nutritional assessment and surgical infections in patients with gastric cancer or peptic ulcer.

Recent reports provide evidence that cancer is frequently associated with malnutrition and infection. This is particularly evident when the gastrointestinal tract is involved. The purpose of this study is to investigate the difference between the nutritional status of patients with gastric cancer and with peptic ulcer, and to determine which of the nutritional indicators may be of value in identifying patients with high risk of postoperative infections. A complete nutritional assessment was performed at admission and the following parameters were determined: hemoglobin, total serum protein, albumin, ceruloplasmin, retinol binding protein, transferrin; Fe; urine creatinine, creatinine/height index, arm muscle circumference; ideal body weight, usual body weight, arm circumference, triceps skinfold; lymphocytes, white blood cells, C3c, skin tests to recall and primary antigens. In the cancer patient group, hemoglobin, total protein, albumin, Fe, percentage usual body weight, and delayed hypersensitivity response to skin antigens were significantly more impaired than in controls. Preoperative delayed hypersensitivity response was the only test in correlation with the tumor stage. It was also significantly different in the gastric cancer patients who developed postoperative infections.

Nutritional and Immunological Evaluations in Cancer Patients. Relationship to Surgical Infections

Several reports provide evidence of the synergism between malnutrition and infection in hospitalized patients. In this study, preoperative complete nutritional assessment (NA) was performed to: 1) evaluate NA modifications in 21 controls with benign minor surgical diseases and in 71 surgical cancer patients; 2) determine the relative value of nutritional and immunological indicators in relation to the postoperative septic complications in cancer patients. The following parameters were used: percent weight loss/month, percent standard arm circumference, percent standard triceps skinfold; hematocrit, hemoglobin, serum proteins, albumin, iron, transferrin, ceruloplasmin, retinol binding protein (RBP); serum creatinine, urine creatinine, creatinine/height index, percent arm muscle circumference; peripheral lymphocytes, white blood cells, complement (C3c), skin tests. In the cancer group percent usual body weight, percent arm muscle circumference, hematocrit, hemoglobin, albumin, iron, ceruloplasmin, retinol binding protein, C3c and delayed hypersensitivity response (DHR) were significantly different from controls. Ceruloplasmin and DHR were the only tests significantly different in the cancer patients who developed postoperative infections. Duration of anesthesia and operative field contamination are other important causative factors which, if associated with malnutrition, may determine a higher susceptibility to infections in surgical cancer patients.