Effects of Nutritional Interventions on Nutritional and Functional Outcomes in Geriatric Rehabilitation Patients: A Systematic Review and Meta-Analysis

Frailty and innovative participatory rehabilitation

This Mini-Review showcases the latest evidence on rehabilitation opportunities for older people with multimorbidity and frailty. There is growing evidence, that a person-centered and contextualized rehabilitation approach may offer benefits, not only in the context of preserving mobility, but especially targeting social participation. Modern rehabilitation aligns with the bio-psycho-social model of the International Classification of Functioning, Disability and Health (ICF), emphasizing the individual and collaboratively determined definition of personalized rehabilitation goals at the activity and participation level. Further studies are warranted to evaluate objective outcome-measurement tools within the domains of activity and participation.

Network analysis of frailty indicators in hospitalized elderly patients: unveiling the role of depression and hemoglobin as core factors

BACKGROUND

Frailty is a significant concern among hospitalized older adults, influenced by multiple factors. Understanding the complex interactions between these variables can be facilitated through a network perspective.

AIM

This study aimed to identify the core factor and physiological indicator of frailty in hospitalized elderly patients and visualize their interactions within the network structure.

METHODS

Frailty was assessed using the Tilburg Frailty Indicators, with a score of 5 or higher indicating frailty. Additional variables related to sociodemographic, physical and clinical, psychological and cognitive aspects, as well as physiological indicators, were extracted from electronic health records. A partial correlation network analysis was conducted using an adaptive LASSO algorithm, based on univariate correlation and logistic regression, to examine the network structure and identify influential nodes.

RESULTS

The average age of participants was 70.74 ± 7.52 years, with 24.27% classified as frail. Frailty was associated with 38 of 145 initially included variables (P < 0.05). The network analysis revealed depression as the most central node, followed by drugs used, sleep disorders, loneliness, masticatory obstacles, drinking, and number of teeth missing. Hemoglobin emerged as the most central biochemical indicator in the network, based on network center index analysis (Strength = 4.858, Betweenness = 223, Closeness = 0.034).

CONCLUSIONS

Frailty in hospitalized older adults is influenced by various social, physical, and psychological factors, with depression as the core factor of utmost importance. Changes in hemoglobin levels could serve as an essential indicator. This innovative network approach provides insights into the multidimensional structure and relationships in real-world settings.

Short-Term Effects of Dietary Protein Supplementation on Physical Recovery in Older Patients at Risk of Malnutrition during Inpatient Rehabilitation: A Pilot, Randomized, Controlled Trial

It is estimated that about 50% of geriatric rehabilitation patients suffer from sarcopenia. Thereby, malnutrition is frequently associated with sarcopenia, and dietary intake is the main modifiable risk factor. During hospitalization, older adults are recommended to consume more dietary protein than the current recommended dietary allowance of 0.8 g/kg body weight per day to optimize the recovery of muscular strength and physical function. This prospective pilot study examined the feasibility and preliminary efficacy of short-term protein supplementation with protein-enriched foods and drinks on the hand-grip strength, nutritional status, and physical function of older patients at risk of malnutrition during a three-week inpatient orthopedic rehabilitation stay. The Mini Nutritional Assessment (MNA) tool was used to assess malnutrition. Patients with an MNA score ≤ 23.5 points were randomly assigned to an intervention group (goal: to consume 1.2-1.5 g protein/kg body weight per day) or a control group (standard care). Both groups carried out the same rehabilitation program. Physical recovery parameters were determined at admission and discharge. A trend was recognized for participants in the intervention group to consume more protein than the control group (p = 0.058): 95.3 (SD 13.2) g/day as compared to 77.2 (SD 24.2) g/day, which corresponds to a mean protein intake of 1.6 (SD 0.3) g/kg/day vs. 1.3 (SD 0.5) g/kg/day. Dietary protein supplementation increased body weight by an average of 0.9 (SD 1.1) kg and fat mass by an average of 0.9 (SD 1.2) kg as compared to the baseline (p = 0.039 and p = 0.050, respectively). No significant change in hand-grip strength, body composition, or physical function was observed. In conclusion, short-term intervention with protein-enriched foods and drinks enabled older patients at risk of malnutrition to increase their protein intake to levels that are higher than their required intake. In these older individuals with appropriate protein intake, dietary protein supplementation did not result in a greater improvement in physical recovery outcomes during short-term inpatient rehabilitation. The intervention improved dietary protein intake, but further research (e.g., a full-scale, randomized, controlled trial with sufficient power) is required to determine the effects on physical function outcomes.

Do dietary supplements prevent loss of muscle mass and strength during muscle disuse? A systematic review and meta-analysis of randomized controlled trials

Objective

We performed a systematic review and meta-analysis of existing randomized controlled trials (RCTs) to assess whether dietary supplements can prevent loss of muscle mass and strength during muscle disuse.

Methods

We searched the following databases: PubMed, Embase, Cochrane, Scopus, Web of Science, and CINAHL for RCTs assessing the effect of dietary supplements on disuse muscular atrophy without language and time restrictions. Muscle strength and leg lean mass were used as the primary outcome indicators. Muscle cross-sectional area (CSA), muscle fiber type distribution, peak aerobic capacity and muscle volume were used as secondary outcome indicators. The risk of bias was assessed using the Cochrane Collaboration's Risk of Bias tool. Heterogeneity was tested using the I² statistic index. Mean and standard deviation of outcome indicators were extracted from the intervention and control groups to calculate effect sizes and 95% confidence intervals, with the significance level set at P < 0.05.

Results

Twenty RCTs were included with a total of 339 subjects. The results showed that dietary supplements had no effect on muscle strength, CSA, muscle fiber type distribution, peak aerobic capacity or muscle volume. But dietary supplements have a protective effect on the lean mass of the legs.

Conclusion

Dietary supplements can improve lean leg mass, but did not show a tendency to have an effect on muscle strength, CSA, muscle fiber type distribution, peak aerobic capacity or muscle volume during muscle disuse.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier: CRD42022370230.

Nutritional Care Practices in Geriatric Rehabilitation Facilities across Europe: A Cross-Sectional Study

Many patients in geriatric rehabilitation (GR) are physically frail at the time of admission and suffer from malnutrition and sarcopenia, which may worsen rehabilitation outcomes. This study aims to obtain insight into the current nutritional care practices in GR facilities across Europe.

METHODS

In this cross-sectional study, a questionnaire focused on nutritional care practices in GR was distributed across experts in EUGMS member countries. Data were analyzed by using descriptive statistics.

RESULTS

In total, 109 respondents working in 25 European countries participated, and the results showed that not all GR patients were screened and treated for malnutrition, and not all participants used (inter)national guidelines when performing nutritional care. The results also showed variations across European geographical areas related to screening and treatment of malnutrition, sarcopenia, and frailty. Even though the participants underlined the importance of dedicating time to nutritional care, they experienced barriers in its implementation, which were mostly due to a lack of resources.

CONCLUSION

As malnutrition, sarcopenia, and frailty are often present in patients admitted to GR, in addition to being interrelated, it is recommended to develop an integrated approach to screening and treatment of all three clinical problems.

Post-discharge consequences of protein-energy malnutrition, sarcopenia, and frailty in older adults admitted to rehabilitation: A systematic review

BACKGROUND & AIMS

Malnutrition, sarcopenia, and frailty are three prevalent wasting conditions among older rehabilitation patients that lead to multiple health-related negative outcomes. This systematic review and meta-analysis aimed to determine the post-discharge consequences of malnutrition, sarcopenia, and frailty in older adults admitted to inpatient rehabilitation.

METHODS

MEDLINE, Embase, Web of Science, and CINAHL databases were searched on 20 April, 2021 for longitudinal studies in older adults (≥65 years) admitted for inpatient rehabilitation. This systematic review included and synthesised studies that 1) measured malnutrition, sarcopenia, and/or frailty using a validated assessment tool or guideline; and 2) reported the association with post-discharge mortality, physical function, quality of life, or discharge location. The Academy of Nutrition & Dietetics Quality Criteria Checklist and GRADE criteria were used to assess risk of bias and evidence certainty. Where possible, data were pooled using Revman.

RESULTS

Twenty-six observational studies (n = 9709 participants in total) with similarly aged populations were included. Eight, seven, and eleven studies assessed malnutrition, sarcopenia, and frailty, respectively. Follow-up periods ranged from immediate to 7 years post-rehabilitation. Malnutrition was associated with discharge to a higher level of care (GRADE: very low), and worse quality of life (GRADE: very low) and physical function (GRADE: very low). Sarcopenia was associated with worse physical function (GRADE: very low) and lower rate of home discharge (OR: 0.14; 95%CI: 0.09-0.20; I²:30%; GRADE: low). Frailty was associated with increased mortality (GRADE: very low), hospital readmission (GRADE: very low), and decreased home discharge (GRADE: very low).

CONCLUSION

Wasting conditions in older adults during rehabilitation admission may be associated with poorer quality of life, lower rates of home discharge, and higher rates of health service use, physical dysfunction, and mortality following discharge. Further research is needed to investigate the comparative and combined impacts, as well as the overlap of malnutrition, sarcopenia, and frailty during and after rehabilitation to guide priority screening and intervention.

Nutritional rehabilitation after acute illness among older patients: A systematic review and meta-analysis

BACKGROUND & AIMS

Acute illness can lead to disability and reduced quality of life in older patients. The aim of this systematic review was to evaluate the effect of nutritional rehabilitation provided during and after hospitalisation for an acute event on functional status, muscle mass, discharge destination and quality of life of older patients.

METHODS

The protocol for this systematic review was registered in PROSPERO (CRD42021264971). Articles were searched using Scopus, Medline, Google Scholar and Clinical.

TRIALS

gov. For studies included in the meta-analysis, Hedges'g standardized mean difference effect size was calculated and transformed in odds ratios.

RESULTS

We identified 7383 articles, of which 45 publications (41 trials, n = 8538 participants, mean age 80.35 ± 7.01 years.) were eligible for the systematic review. Patients were hospitalized for acute medical diseases (n = 6925) and fractures (n = 1063). The interventions included supplementation with a fixed amount of oral nutritional supplements (ONS, n = 17 trials), individualized diet plan (n = 3), combination of physical exercise with nutrition therapy (n = 14 trials), combination of anabolic agents with nutrition therapy (n = 5 trials). Overall nutritional rehabilitation improved functional status (Odds ratio 1.63 [1.15; 2.3], p = 0.003) and muscle mass (Odds ratio 2.61 [1.22; 5.5], p = 0.01), but not the quality of life or the discharge destination.

CONCLUSION

Nutritional rehabilitation was found to improve functional status and muscle mass. There is a need for larger studies involving older hospitalized patients.

Nutrition Intervention Informed by Indirect Calorimetry Compared to Predictive Equations to Achieve Weight Goals in Geriatric Rehabilitation Inpatients: The NEED Study

OBJECTIVES

To assess if nutritional interventions informed by indirect calorimetry (IC), compared to predictive equations, show greater improvements in achieving weight goals, muscle mass, strength, physical and functional performance.

DESIGN

Quasi-experimental study.

SETTING AND PARTICIPANTS

Geriatric rehabilitation inpatients referred to dietitian.

INTERVENTION AND MEASUREMENTS

Patients were allocated based on admission ward to either the IC or equation (EQ) group. Measured resting metabolic rate (RMR) by IC was communicated to the treating dietitian for the IC group but concealed for the EQ group. Achieving weight goals was determined by comparing individualised weight goals with weight changes from inclusion to discharge (weight gain/loss: >2% change, maintenance: ≤2%). Muscle mass, strength, physical and functional performance were assessed at admission and discharge. Food intake was assessed twice over three-days at inclusion and before discharge using plate waste observation.

RESULTS

Fifty-three patients were included (IC n=22; EQ n=31; age: 84.3±8.4 years). The measured RMR was lower than the estimated RMR within both groups [mean difference IC -282 (95%CI -490;-203), EQ -273 (-381;-42) kcal/day)] and comparable between-groups (median IC 1271 [interquartile range 1111;1446] versus EQ 1302 [1135;1397] kcal/day, p=0.800). Energy targets in the IC group were lower than the EQ group [mean difference -317 (95%CI -479;-155) kcal/day]. There were no between-group differences in energy intake, achieving weight goals, changes in muscle mass, strength, physical and functional performance.

CONCLUSIONS

In geriatric rehabilitation inpatients, nutritional interventions informed by IC compared to predictive equations showed no greater improvement in achieving weight goals, muscle mass, strength, physical and functional performance. IC facilitates more accurate determination of energy targets in this population. However, evidence for the potential benefits of its use in nutrition interventions was limited by a lack of agreement between patients' energy intake and energy targets.

Nutritional Management in Adult Patients With Dysphagia: Position Paper From Japanese Working Group on Integrated Nutrition for Dysphagic People

This position paper prepared by the Japanese Working Group on Integrated Nutrition for Dysphagic People (JWIND) aims to summarize the need for nutritional management in adult patients with dysphagia, the issues that nutrition professionals should address, and the promising approaches as well as to propose a vision for the future of nutritional care for adult patients with dysphagia. JWIND is a joint certification system recognized by the Japan Dietetic Association and the Japanese Society of Dysphagia Rehabilitation; its members are mostly experts known as "Certified Specialist of Registered Dietitian for Dysphagia Rehabilitation." Malnutrition and dysphagia are associated with each other. Therefore, malnutrition detection and intervention are essential for patients with dysphagia. However, evidence on the usefulness nutritional assessment and intervention to ensure appropriate nutritional care remains insufficient. Here, we present current knowledge of the relationship between primary diseases causing dysphagia and malnutrition, the indicators used for nutritional assessment, and nutritional interventions such as texture-modified diet (TMD) quality improvement, oral nutritional supplementation, and comprehensive intervention. We also discuss the current status and issues in nutritional care for adult patients with dysphagia. Furthermore, we have proposed measures that nutrition professionals should consider based on 3 perspectives: nutritional assessment, TMD, and nutritional intervention. Individualized and specialized nutritional management by registered dietitians (RDs) through appropriate assessment of the nutritional status of adult patients with dysphagia is needed. To maintain and improve swallowing function and nutritional status, RDs should intervene from the state of risk or early dysphagia onset, providing individualized care per their expertise as part of a multidisciplinary team. However, systematic clinical practice and research regarding the association of nutrition with dysphagia are currently insufficient. Therefore, further clinical practice and evidence building, including the verification of the efficacy on nutritional support through intervention research, are needed.

Combating sarcopenia in geriatric rehabilitation patients: study protocol of the EMPOWER-GR observational cohort, sarcopenia awareness survey and randomised controlled feasibility trial

INTRODUCTION

Sarcopenia is highly prevalent in geriatric rehabilitation patients. Resistance exercise training (RET) combined with protein supplementation is recommended to increase muscle mass and strength in older adults. However, sarcopenia awareness, feasibility to diagnose and treat sarcopenia, and efficacy of treatment in geriatric rehabilitation patients remain to be established.

METHODS AND ANALYSIS

Enhancing Muscle POWER in Geriatric Rehabilitation (EMPOWER-GR) encompasses four pillars: (1) an observational cohort study of 200 geriatric rehabilitation inpatients determining sarcopenia prevalence, functional and nutritional status at admission; (2) a survey among these 200 patients and 500 healthcare professionals and semistructured interviews in 30 patients and 15 carers determining sarcopenia awareness and barriers/enablers regarding diagnostics and treatment; (3) a feasibility, single-centre, randomised, controlled, open-label, two parallel-group trial in 80 geriatric rehabilitation patients with sarcopenia. The active group (n=40) receives three RET sessions per week and a leucine and vitamin D-enriched whey protein-based oral nutritional supplement two times per day in combination with usual care for 13 weeks. The control group (n=40) receives usual care. Primary outcomes are feasibility (adherence to the intervention, dropout rate, overall feasibility) and change from baseline in absolute muscle mass at discharge and week 13. Secondary outcomes are feasibility (participation rate) and change from baseline at discharge and week 13 in relative muscle mass, muscle strength, physical and functional performance, mobility, nutritional status, dietary intake, quality of life and length of stay; institutionalisation and hospitalisation at 6 months and mortality at 6 months and 2 years; (4) knowledge sharing on sarcopenia diagnosis and treatment.

ETHICS AND DISSEMINATION

Ethical exemption was received for the observational cohort study, ethics approval was received for the randomised controlled trial. Results will be disseminated through publications in scientific peer-reviewed journals, conferences and social media.

TRIAL REGISTRATION NUMBER

NL9444.

Protein Nutritional Status and Frailty: A Mendelian Randomization Study

BACKGROUND

Observational studies have suggested that better protein nutritional status may contribute to prevention of frailty.

OBJECTIVE

We sought to examine this hypothesis using a Mendelian randomization (MR) analysis.

METHODS

We conducted a two-sample MR study using GWAS summary statistics data of the UK Biobank. We applied genetically predicted serum albumin as a primary exposure measure and serum total protein as a secondary exposure measure. The outcome measure was the Rockwood frailty index (FI) based on 49 deficits from 356,432 individuals (53.3% of them were women, with a mean ± SD age of 56.7 ± 8.0 y. The association between serum protein measures and FI was mainly analyzed by use of the inverse variance weighted method.

RESULTS

A genetically predicted serum albumin concentration was not statistically significantly associated with FI in the full sample. However, in women, we observed a preventive association between genetically predicted serum albumin and FI (β = -0.172 per g/L; 95% CI: -0.336, -0.007; P = 0.041). In the full sample, genetically predicted serum total protein was inversely associated with FI (β: -0.153 per g/L; 95% CI: -0.251, -0.056; P = 0.002). In both women and men, higher serum total protein was significantly inversely associated with FI; regression coefficients were -0.148 per g/L (95% CI: -0.287, -0.009; P = 0.037) for women, -0.154 per g/L (95% CI: -0.290, -0.018; P = 0.027) for men.

CONCLUSIONS

The present MR study implies that better protein nutritional status modestly contributes to reducing the risk of frailty.

Stored Energy Increases Body Weight and Skeletal Muscle Mass in Older, Underweight Patients after Stroke

We conducted a retrospective observational study in 170 older, underweight patients after stroke to elucidate whether stored energy was associated with gains in body weight (BW) and skeletal muscle mass (SMM). Energy intake was recorded on admission. The energy requirement was estimated as actual BW (kg) × 30 (kcal/day), and the stored energy was defined as the energy intake minus the energy requirement. Body composition was measured by bioelectrical impedance analysis. The study participants gained an average of 1.0 ± 2.6 kg of BW over a mean hospital stay of 100 ± 42 days with a mean stored energy of 96.2 ± 91.4 kcal per day. They also gained an average of 0.2 ± 1.6 kg of SMM and 0.5 ± 2.3 kg of fat mass (FM). This means about 9600 kcal were needed to gain 1 kg of BW. In addition, a 1 kg increase in body weight resulted in a 23.7% increase in SMM and a 45.8% increase in FM. Multivariate regression analyses showed that the stored energy was significantly associated with gains in BW and SMM. Aggressive nutrition therapy is important for improving nutritional status and function in patients with malnutrition and sarcopenia.

The Relevance of Obesity for Activities of Daily Living in Geriatric Rehabilitation Patients

The obesity pandemic has reached old age but the effect of obesity on functional recovery in geriatric rehabilitation patients has not been investigated to date. In this prospective cohort study, patients admitted into geriatric rehabilitation were consecutively included between September 2015 and September 2016, aged ≥70 years. Individual activities of daily living were documented by the Barthel index (BI, 0–100 points). Obesity was assessed by the measurement of body mass index (BMI, kg/m²), waist circumference (WC, cm) and percentage of body fat mass (%FM) based on triceps’ skinfold thickness at admission (t1), discharge (t2) and six months after discharge (t3). A total of 122 patients were included in the analysis. Prevalence of obesity according to BMI, WC and %FM was 33.6%, 83.6% and 71.3% respectively. Patients with a high WC and patients with a high BMI had lower BI values at t1, t2, t3 and the improvement in BI (t1–t2, t2–t3) was lower than in those with low WC and low BMI, but without statistical significance. In multiple regression analysis, BMI, WC and %FM were not associated with BI at t3 and improvement of BI (t2–t3). Obesity was highly prevalent in geriatric rehabilitation patients, but it was not associated with BI during the 6-month follow-up.

Results of High-Protein, High-Calorie Oral Nutritional Supplementation in Malnourished Older People in Nursing Homes: An Observational, Multicenter, Prospective, Pragmatic Study (PROT-e-GER)

OBJECTIVES

To assess if the impact of oral nutritional supplements (ONS) on nutritional and functional status in malnourished older persons living in nursing homes shown by clinical trials are also found outside a trial setting.

DESIGN

Observational, multicenter, prospective, pragmatic study.

SETTING AND PARTICIPANTS

This study was carried out in 38 nursing homes throughout Spain. Nursing home physicians recruited consecutive residents, older than 65 years, with a diagnosis of malnutrition, when a clinical decision to start ONS had been taken after unsuccessful initial management with dietary interventions.

INTERVENTION

The participants received daily 2 bottles of an energy-rich, high-protein commercial ONS for 3 months.

MEASURES

Primary outcomes were changes in nutritional status [body weight, body mass index (BMI), and Mini Nutritional Assessment-Short Form (MNA-SF)]; secondary outcomes were functional changes [Functional Ambulation Classification, Barthel index, handgrip strength, and Short Physical Performance Battery (SPPB)], as well as safety and adherence after 12 weeks of follow-up.

RESULTS

A total of 282 residents (median age 86 years, 67% women) were included, and 244 (86.5%) completed the follow-up. At baseline, 77.3% of the participants were malnourished (BMI 19.7 kg/m², interquartile range 18.3-21.8). After 12 weeks of follow-up, participants experienced significant increases in body weight (2.6 ± 3.1 kg, 5.2 ± 5.9%), BMI (1.0 ± 1.2 kg/m²) and MNA-SF (4.0 ± 2.5 points). There were also significant improvements in functional status measured by the Barthel index, handgrip strength, SPPB, and gait speed. Good adherence was registered in 94.6% of the participants. No relevant side effects were found.

CONCLUSIONS AND IMPLICATIONS

Improvements in nutritional and functional status can be found when using a high-protein, high-calorie ONS in older undernourished people living in nursing homes.

Association between malnutrition and stages of sarcopenia in geriatric rehabilitation inpatients: RESORT

BACKGROUND & AIMS

Malnutrition and sarcopenia coexist in older adults, yet they remain largely undiagnosed and untreated, despite available interventions. This study aimed to assess the prevalence, the coexistence of, and the association between malnutrition and sarcopenia in geriatric rehabilitation inpatients.

METHODS

REStORing health of acutely unwell adulTs (RESORT) is an observational, longitudinal cohort of geriatric rehabilitation inpatients. The association between malnutrition, diagnosed according to the Global Leadership Initiative on Malnutrition (GLIM) criteria and sarcopenia according to the revised definition of the European Working Group on Sarcopenia in Older People (EWGSOP2) (no sarcopenia, probable sarcopenia, confirmed sarcopenia and severe sarcopenia) was determined using multinomial logistic regression analyses, adjusted for age, sex, comorbidities and cognitive impairment.

RESULTS

Out of 506 geriatric rehabilitation inpatients, 51% were malnourished, 49% had probable sarcopenia, 0.4% had confirmed sarcopenia (non-severe) and 19% had severe sarcopenia. Malnutrition and probable sarcopenia and malnutrition and confirmed/severe sarcopenia coexisted in 23% and 13% of the 506 patients respectively. Malnutrition was not associated with probable sarcopenia (OR = 0.91, 95% CI = 0.58-1.42, p = 0.674) but with severe sarcopenia (OR = 2.07, 95% CI = 1.13-3.81, p = 0.019).

CONCLUSION

The prevalence, coexistence of, and the association between malnutrition and severe sarcopenia in geriatric rehabilitation inpatients warrant diagnosis at admission. Further research into feasible and effective interventions to counteract both conditions to improve geriatric rehabilitation outcomes is needed.

Nutritional Assessment in Older Adults : MNA® 25 years of a Screening Tool and a Reference Standard for Care and Research; What Next?

A tool to assess nutritional status in older persons was really needed. It took 5 years to design the MNA® (Mini Nutrition Assessment) tool, complete the first validations studies both in Europe and in the U.S. and to publish it. After the full MNA®, the MNA® short form and the self-MNA® have been validated. As well as Chinese and other national MNA® forms. Now more than 2000 clinical research have used the MNA® all over the world from community care to hospital. At least 22 Expert groups included the MNA® in new clinical practice guidelines, national or international registries. The MNA® is presently included in almost all geriatric and nutrition textbook and part of the teaching program for medicine and other health care professional worldwide. The urgent need is to target the frail older adults more likely to have weight loss and poor appetite and to prevent frailty and weight loss in the robust. We present in this paper the review of 25 years of clinical research and practice using the MNA® worldwide.