Nutrition

The breath print represents a novel biomarker of malnutrition in pulmonary arterial hypertension: A proof of concept study

BACKGROUND

The breath print is a quantitative measurement of molecules in exhaled breath and represents a new frontier for biomarker identification. It is unknown whether this state-of-the-art, noninvasive method can detect malnutrition. We hypothesize that individuals with malnutrition will present with a distinguishable breath print.

METHODS

We conducted a retrospective chart review on patients with previously analyzed breath samples to identify malnutrition. Breath was analyzed by selected-ion flow-tube mass spectrometry. Registered dietitians conducted a retrospective chart review to collect malnutrition diagnoses and nutrition status indicators. Patients were categorized into one of four groups: pulmonary arterial hypertension (PAH), PAH with malnutrition (PAH-Mal), control, and control with malnutrition (Control-Mal), based on the malnutrition diagnosis present in the patient's chart. Principle component analysis was conducted to characterize the breath print. A logistic regression model with forward selection was used to detect the best breath predictor combination of malnutrition.

RESULTS

A total of 74 patients met inclusion criteria (PAH: 52; PAH-Mal: 10; control: 10; Control-Mal: 2). Levels of 1-octene (PAH-Mal, 5.1 ± 1.2; PAH, 12.5 ± 11.2; P = 0.005) and ammonia (PAH-Mal, 14.6 ± 15.8; PAH, 56.2 ± 64.2; P = 0.013) were reduced in PAH-Mal compared with PAH. The combination of 1-octene (P = 0.010) and 3-methylhexane (P = 0.045) distinguished malnutrition in PAH (receiver operating characteristic area under the curve: 0.8549).

CONCLUSIONS

This proof of concept study provides the first evidence that the breath print is altered in malnutrition. Larger prospective studies are needed to validate these results and establish whether breath analysis may be a useful tool to screen for malnutrition in the clinical setting.

Antepartum Bed Rest: Maternal Weight Change and Infant Birth Weight

Despite lack of evidence for effectiveness, obstetricians in the United States prescribe antepartum bed rest for more than 700,000 women per year. However, in nonpregnant samples, bed rest treatment produces weight loss. This study assessed maternal weight change (gain) during antepartum hospitalization for bed rest treatment; compared appropriateness of infant birth weights for gestational age, race, and gender; and determined whether maternal weight change predicted infant birth weight. The convenience sample for this longitudinal study consisted of 141 women with high-risk pregnancies who were treated with hospital bed rest. Weekly rate of pregnancy weight change by body mass index was compared with Institute of Medicine recommendations for rate of pregnancy weight gain. Infant birth weight was compared with current US infant birth weights for matching gestational age, gender, and race. Weekly antepartum weight change was significantly lower than Institute of Medicine recommendations (P < 0.001). Infant birth weights were also significantly lower than the national mean when matched for each infant’s gestational age, race, and gender ( P < 0.001). Maternal weight change predicted infant birth weight ( P = 0.05). Bed rest treatment is ineffective for improving pregnancy weight gain. Lower infant birth weights across all gestational ages suggest that maternal weight loss during bed rest may be associated with an increased risk of fetal growth restriction. A randomized trial comparing women with high-risk pregnancies who are ambulatory with those on bed rest is needed to determine whether bed rest treatment, underlying maternal-fetal disease, or both influence inadequate maternal weight gain and poor intrauterine growth.

Tube feeding in the elderly

Tube feeding is an art and a science that is increasingly used in our aging society as more people become physically incapacitated or have dementia. Properly used, tube feeding can be helpful. However, patients should be monitored for tolerance and complications and assessed for a possible return to oral feeding. The joy of eating, one of the pleasures in life, should not be denied if at all possible.

Evaluation of Parenteral Nutrition Management in a Hospital without a Formal Nutrition Support Team

Purpose

A preliminary review of several adult inpatients receiving parenteral nutrition (PN) revealed opportunities for improvement. In response, a drug usage evaluation (DUE) was conducted to: 1) determine specific areas of adult PN management needing improvement; 2) evaluate the current PN order forms; 3) identify reasons for PN wastage; 4) establish pharmacist involvement in prescribing/monitoring of PN in a community hospital without a formal nutrition support team.

Methods

A prospective DUE was performed on various adults receiving PN from January through February 2005. The following data were collected and evaluated: 1) PN indication; 2) whether ordered PN formula met patients' estimated needs; 3) adequate adjustments of electrolyte or glucose imbalances; 4) appropriate ramping/tapering of PN; 5) appropriate laboratory data ordered. Additionally, a record was kept of PN solutions wasted from January through April 2005.

Results

Twenty-two adult patients receiving PN were prospectively reviewed. Protein and caloric needs were met in only 59% of patients (n = 13), and electrolytes were abnormal in 73% of patients (n = 16), with most physicians making minimal or no electrolyte adjustments. PN was not routinely ramped up upon initiation. Phosphorus, triglycerides, and prealbumin were not routinely monitored. An average of 14.5 PN bags was wasted per month. In response to these findings, the PN order forms were redesigned to facilitate appropriate monitoring and to facilitate physician-initiated consults for pharmacists to manage PN. One year after implementation, a 40% reduction in PN wastage was noted.

Conclusions

Pharmacists play an integral role in PN management, resulting in improved patient monitoring and a reduction in expensive PN wastage.

The effects of undernutrition and refeeding on metabolism and digestive function

PURPOSE OF REVIEW

An intimate interrelationship exists between nutritional status and gut function. This review focuses on the consequences of a poor nutritional state on metabolism and digestive function, and evaluates the effects of refeeding.

RECENT FINDINGS

Severe undernutrition has been associated with increased fat and protein catabolism, reflected by a decreased respiratory quotient. Resting energy expenditure assessed in relationship to body weight was increased, probably as a consequence of changes in body composition. Protein synthesis, expressed per kg body weight, was decreased in undernourished patients with coexistent disease, but not in anorexia nervosa patients, indicating the detrimental effects of disease states. Severe undernutrition is associated with malabsorption, which improves following refeeding. Despite a high prevalence of villous atrophy in the duodenal mucosa in undernourished patients, mucosal protein fractional synthesis rates appeared normal. Refeeding resulted in a potent trophic response, and normalization of the mucosal morphology. Gastric and pancreatic secretion was significantly impaired by the undernourished state, with significant improvement following refeeding.

SUMMARY

Undernutrition is associated with impairment of digestive function, which is likely to further aggravate the nutritional state. Refeeding corrects this dysfunction, and results in disruption of this vicious circle.

Nutrition and food allergies: the dietitian's role

BACKGROUND

A varied nutrient intake provides the opportunity for an adequate nutrient intake balance while reducing malnutrition risks. When a food allergy diagnosis has been made, medical nutrition therapy with scheduled follow-up visits can provide a way to monitor the overall health effects of food elimination. Identifying individuals at risk may protect and possibly improve the patient's nutritional and overall health status. Medical nutrition therapy with appropriate food allergen substitution(s) provides the tools necessary giving the food-allergic patient the specific focus needed for improved nutrition self-care and food allergen avoidance.

OBJECTIVE

To reduce the food allergic patient's risk of developing malnutrition by providing exceptional nutrition intervention.

DATA SOURCES

Review of the literature with clinical perspectives.

CONCLUSIONS

The food-allergic patient is less likely to develop nutrient deficiencies or malnutrition when provided with appropriate food alternatives and careful monitoring while eliminating the food allergen(s), short- or long-term, from the diet. The dietitian is the most qualified professional to address the food-allergic patient's medical nutrition therapy needs.

Increasing fecal butyrate in ulcerative colitis patients by diet: controlled pilot study

Topical butyrate has been shown to be effective in the treatment of ulcerative colitis (UC). Butyrate is derived from colonic fermentation of dietary fiber, and our aim was to study whether UC patients could safely increase the fecal butyrate level by dietary means. We enrolled 22 patients with quiescent UC (mean age, 44 years; 45% women; median time from last relapse, 1 year) in a controlled pilot trial lasting 3 months. The patients were instructed to add 60 g oat bran (corresponding to 20 g dietary fiber) to the daily diet, mainly as bread slices. Fecal short-chain fatty acids (SCFAs) including butyrate, disease activity, and gastrointestinal symptoms were recorded every 4 weeks. During the oat bran intervention the fecal butyrate concentration increased by 36% at 4 weeks (from 11 +/- 2 (mean +/- SEM) to 15 +/- 2 micromol/g feces) (p < 0.01). The mean butyrate concentration over the entire test period was 14 +/- 1 micromol/g feces (p < 0.05). Remaining fecal SCFA levels were unchanged. No patient showed signs of colitis relapse. Unlike controls, the patients showed no increase in gastrointestinal complaints during the trial. Yet patients reporting abdominal pain and reflux complaints at entry showed significant improvement at 12 weeks that returned to baseline 3 months later. This pilot study shows that patients with quiescent UC can safely take a diet rich in oat bran specifically to increase the fecal butyrate level. This may have clinical implications and warrants studies of the long-term benefits of using oat bran in the maintenance therapy in UC.

Special feature: exploring the benefits and myths of enteral feeding in the critically ill

Patients in the intensive care unit setting have been nutritionally deprived for various reasons. Many patients who are critically ill cannot absorb nourishment by traditional routes. Enteral feeding should be considered for all patients who cannot meet caloric needs. There are many benefits to enteral feeding such as decreased infection, rapid wound healing, and decreased length of stay and mortality. Many critical care nurses subscribe to myths for not feeding their patients. The myths for not feeding critically ill patients involve gut motility, feeding residuals, and patient positioning. There is significant evidence both to support nutrition as integral to recovery from a critical illness and to suggest that enteral feeding is efficient and effective at providing nutrition.