Barriers to adequate protein nutrition among hemodialysis patients

Exploring Problems in Following the Hemodialysis Diet and Their Relation to Energy and Nutrient Intakes: The BalanceWise Study

OBJECTIVE

To identify the problems experienced by hemodialysis (HD) patients in attempting to follow the HD diet and their relation to energy and nutrient intakes.

DESIGN

Cross-sectional analysis of baseline data from the BalanceWise Study.

SUBJECTS

Participants included community-dwelling adults recruited from outpatient HD centers. After excluding participants with incomplete dietary analyses (n = 50), 140 African American and white (40/60%) men and women (52/48%) on chronic intermittent HD for at least 3 months (median 3 years) were included.

INTERVENTION

Participant responses, on a 5-point Likert scale ranging from "not at all a problem" to "a very important problem for me," to 34 questions pertaining to potential barriers to following the HD diet in the previous 2 months were classified as either a problem (1) or not a problem (2-5).

MAIN OUTCOME MEASURE

Energy and nutrient intakes determined using the Nutrition Data System for Research® based on 3, non-consecutive, unscheduled, 2-pass 24-hour dietary recalls collected on 1 dialysis and 1 non-dialysis weekday, and 1 non-dialysis weekend day.

RESULTS

More than half of participants reported having problems related to specific behavioral factors (e.g., feeling deprived), technical difficulties (e.g., tracking nutrients), and physical condition (e.g., appetite), but issues of time and food preparation and behavioral factors tended to be most deterministic of reported dietary intakes. Longer duration of HD was associated with lower intakes of protein, potassium, and phosphorus (P < .05).

CONCLUSION

Registered dietitian nutritionists should consider issues of time and food preparation, and behavioral factors in their nutrition assessment of HD patients and should continually monitor HD patients for changes in protein intake that may occur over time.

A randomized, placebo-controlled, phase 2 study of the efficacy and safety of droxidopa in patients with intradialytic hypotension

INTRODUCTION

Intradialytic hypotension (IDH) is the most common complication of hemodialysis (HD), and it plays a significant role in the morbidity and mortality associated with maintenance HD.

METHODS

This was a placebo-controlled, parallel-group study evaluating efficacy and safety of droxidopa in improving intradialytic blood pressure (BP) responses in 85 adults with end-stage renal disease (ESRD) and prone to IDH. Following screening and baseline periods, patients received 400 mg or 600 mg droxidopa, or placebo, orally 1 hour before HD for 4 weeks. Primary outcome endpoint was the change between baseline and last 2 treatment weeks in average mean arterial pressure (MAP) during HD. Also assessed were changes from baseline in systolic BP (SBP) and diastolic BP (DBP) during and after HD; number of hypotension-induced interventions and symptoms; and adverse events.

RESULTS

Increase in droxidopa intra-HD MAP were not significantly different from placebo, although droxidopa groups showed significant improvements in mean SBP after HD of +4.8 ± 11.6 mm Hg (600-mg) and +3.4 ± 13.1 (400-mg) compared with -4.4 ± 17.9 mm Hg in placebo, and the drop seen in mean nadir SBP pre- to intra-HD was also reduced. Changes in mean DBP pre- and post-HD, changes in mean nadir SBP post-HD, or intra-HD SBP were not significant over the treatment period. HD terminations decreased 5-fold in the 600-mg group and 2-fold in the 400-mg group, whereas the number of discontinuations stayed unchanged in the placebo group. Overall, treatment with 600-mg or 400-mg droxidopa was well tolerated in this population.

CONCLUSION

These data suggest that droxidopa may have a role in reducing IDH complications in patients with ESRD on chronic HD.

Major barriers responsible for malnutrition in hemodialysis patients: challenges to optimal nutrition

Background:

Nutritional barriers may contribute to malnutrition in hemodialysis (HD) patients. Higher rates of morbidity and mortality rates have been reported in malnourished HD patients. These patients are faced with different challenges affecting their nutritional status.

Objectives:

The aim of this cross-sectional study was to identify most important barriers responsible for malnutrition in HD patients.

Patients and Methods:

We randomly selected 255 of 800 stable HD patients from three HD centers with an age range of 18-85 years, who had been on hemodialysis for at least three months without any acute illness. Each patient was interviewed to evaluate malnutrition [subjective global assessment (SGA), malnutrition inflammation score (MIS)], and potential medical, behavioral and socioeconomic barriers. Body composition of patients was checked through bioelectrical impedance analysis (BIA). Routine clinical markers of malnutrition such as serum albumin and total protein were measured using standard automated techniques. Binary logistic regression model was used to find the association between nutritional markers and potential barriers.

Results:

Patients with higher SGA had lower knowledge about general nutrition [odds ratio (OR), 1.3], potassium (OR, 1.89), difficulty chewing (OR, 1.16), and shopping (OR, 1.16). Those with greater MIS scores had poor appetite (OR, 1.3), depression (OR, 1.21), and difficulty with cooking (OR, 1.15). Lower BCM (body cell mass) was associated with poor appetite (OR, 0.92) and needed help for cooking (OR, 0.88). Patients with higher BFMI (body fat mass index) had insufficient general nutrition (OR, 1.15), and protein (OR, 1.27) knowledge, and needed help for shopping (OR, 1.14). Moreover, patients with higher SGA scores were those with older age and longer duration of HD.

Conclusions:

Three medical barriers (poor appetite, depression and difficulty chewing), one behavioral barrier (poor total nutrition, protein, and potassium knowledge), and one socioeconomic barrier (needing help for shopping and cooking) were independently associated with nutritional markers.

Dietary and fluid adherence in Iranian hemodialysis patients

Adherence to fluid restrictions and dietary and medication guidelines is important for adequate management of hemodialysis (HD) patients. This study aimed at assessing the factors suggestive of adherence in uremic patients on HD. Two hundred HD patients were recruited by census method. Data on blood urea nitrogen (BUN), serum potassium and phosphate levels, and interdialytic weight gain (IWG) were collected from medical records and analyzed. Most of the patients (56%) did not adhere to fluid restrictions. Nonadherence to phosphate, potassium, and BUN levels was 25.5%, 5.5%, and 4.5%, respectively. In addition, there was a relationship between BUN, serum potassium and phosphate levels, and IWG with educational status (p ≤ .05). However, there was no correlation between BUN, serum potassium and phosphate levels, and IWG with sex, age, financial status, marital status, and duration of dialysis (p > .05). Based on the results, most of the patients adhered to dietary and medication regimens. Educational level of the patients was associated with adherence to fluid restriction. It was concluded that dietary compliance may be improved by using dietary counseling techniques and that education motivates patients to change and comply with dietary recommendations.

Effects of peridialytic oral supplements on nutritional status and quality of life in chronic hemodialysis patients

OBJECTIVE

Our objective was to determine the effects of peridialytic oral supplements on nutritional markers and quality of life (QOL) in patients receiving maintenance hemodialysis.

DESIGN

This trial was open, prospective, nonrandomized, and comparative.

SETTING

This study was performed at an outpatient hemodialysis unit in a teaching hospital.

PATIENTS

This study included 88 adults with chronic kidney disease at stage 5.

INTERVENTION

This study involved directly observed nutrition therapy with >or=1 can of enteral nutrition (Nepro) with each hemodialysis session thrice weekly for 3 months, or standard care.

MAIN OUTCOME MEASURE

Changes in biochemical markers of nutritional status and QOL, as measured by the Kidney Disease Quality of Life-Short Form, were determined.

RESULTS

Peridialytic oral nutrition resulted in a significant difference between the nutrition and comparison groups in serum albumin change over time (P = .03; repeated-measures analysis of variance with covariates). Mean (+/-SD) serum albumin concentration did not differ between baseline and month 3 in the nutrition group (3.68 +/- 0.33 g/dL vs. 3.75 +/- 0.40 g/dL; P = .12), but in the comparison group, serum albumin levels declined significantly (3.93 +/- 0.34 g/dL at baseline versus 3.81 +/- 0.37 g/dL at month 3; P = .04). The "role-physical" domain score of the Kidney Disease Quality of Life-Short Form significantly changed over time in the nutrition group versus the comparison group (P = .02; repeated-measures analysis of variance with covariates). Nepro was well-tolerated, and greater than 80% of the prescribed therapy was consumed.

CONCLUSION

Oral nutrition, as part of structured, directly observed peridialytic therapy in chronic hemodialysis patients, was well-accepted, and resulted in the maintenance of serum albumin levels and QOL with respect to impact of physical health on daily activities. These findings need to be confirmed in a randomized, controlled trial.

Public health approach to addressing hyperphosphatemia among dialysis patients

Elevated serum phosphorus levels are a major source of morbidity and mortality for the 350,000 Americans receiving chronic dialysis treatment. Despite the widespread application of medical and behavioral interventions, the prevalence of hyperphosphatemia remains exceedingly high. At first glance, a public health perspective may seem inappropriate for addressing a disorder of mineral metabolism among patients receiving a life-sustaining treatment. However, we analyzed this topic from a public health perspective and identified many opportunities to improve the management of hyperphosphatemia, including (1) media and cultural messages about food, (2) the availability of appropriate foods and medications, (3) physical structures such as the location of products in grocery stores, and (4) social structures such as food-labeling laws.

Dietary adherence in Hispanic patients receiving hemodialysis

OBJECTIVES

The study objective was to identify the factors that influence dietary adherence in Hispanic patients receiving maintenance hemodialysis and to determine the differences in dietary adherence between Hispanic and non-Hispanic patients.

DESIGN

We performed a cross-sectional study using a descriptive-comparative design.

SETTING

The study took place at hemodialysis centers at Winthrop-University Hospital, New York.

PARTICIPANTS

The participants were adult patients of Hispanic descent receiving maintenance hemodialysis three times per week for 3 months or more and an equal number of age- and sex-matched non-Hispanic patients.

INTERVENTION

Information was obtained by a questionnaire about knowledge of the diet, preferred language for education, consumption of potassium- (K(+)) and phosphorus- (PO(4)) containing foods, and adherence attitudes and behaviors. Serum albumin (SAlb), K(+), and PO(4) for the past 3 months were obtained from medical records and evaluated to assess dietary adherence.

MAIN OUTCOME MEASURE

The main outcome measure was a mean SAlb of 3.2g/dL or greater, K(+) of 5.5 mEq/L or less, and PO(4) of 5.5 mg/dL or less.

RESULTS

A total of 17 Hispanic and 17 comparison patients were included. Both groups were adherent to the diet because their mean levels of SAlb, K(+), and PO(4) were within acceptable limits. Dietary adherence was observed in 76% of the Hispanic patients for SAlb, 88% for K(+), and 65% for PO(4), whereas the rate of adherence was 59%, 88%, and 76%, respectively, for the comparison group.

CONCLUSION

Both groups were adherent to the restrictions of the renal diet. More patients from both groups were adherent to K(+) than to PO(4) restrictions. Among the factors that probably influenced dietary adherence to the renal diet in this dialysis facility are knowledge of the renal diet, language, food frequency consumption, socioeconomic status, family support, and attitudes toward the renal diet. Patient education provided in Spanish with family involvement is an important element for promoting adherence among Hispanic patients receiving dialysis.

Improving Albumin Levels Among Hemodialysis Patients: A Community-Based Randomized Controlled Trial

BACKGROUND

Low albumin level is a strong predictor of mortality and morbidity among hemodialysis patients, yet few interventions are available to improve albumin levels. Moreover, the relative importance of nutritional barriers versus inflammation in contributing to hypoalbuminemia is unclear. We sought to determine whether targeting specific nutritional barriers will improve albumin levels.

METHODS

We conducted a randomized controlled trial involving 180 patients with baseline albumin levels less than 3.7 g/dL (<37 g/L) at 44 long-term hemodialysis facilities. Study coordinators identified and intervened on specific barriers present among intervention patients, whereas control patients continued to receive the usual care. Barriers targeted included poor nutritional knowledge, poor appetite, help needed with shopping or cooking, low fluid intake, inadequate dialysis dose, depression, difficulty chewing, difficulty swallowing, gastrointestinal symptoms, and acidosis.

RESULTS

At baseline, intervention and control patients had similar albumin levels, dietary intakes, levels of inflammatory markers, and numbers of nutritional barriers. After 12 months, intervention patients had greater increases in albumin levels compared with control patients (+0.21 versus +0.06 g/dL [+2.1 versus +0.6 g/L]; P < 0.01), as well as greater increases in energy intake (+4.1 versus -0.6 Kcal/d/kg; P < 0.001) and protein intake (+0.13 versus -0.06 g/d/kg; P < 0.001). The intervention appeared most effective for barriers related to poor nutritional knowledge, help needed with shopping or cooking, and difficulty swallowing. About half the subjects had elevated levels of inflammatory markers, but there was no relationship between change in levels of albumin and inflammatory markers.

CONCLUSION

A nutrition intervention tailored to patient-specific barriers resulted in modest improvements in albumin levels regardless of levels of inflammatory markers.

Nonadherence With Diet and Fluid Restrictions Among Adults Having Hemodialysis

PURPOSE

To describe the prevalence of nonadherence with the prescribed diet and fluid restrictions among patients receiving hemodialysis.

METHODS

A multicenter cross-sectional design with 916 patients recruited from 18 dialysis centers in Germany and Belgium. The Dialysis Diet and Fluid Nonadherence Questionnaire (DDFQ) was used to measure patients' nonadherence.

FINDINGS

The results showed that many patients had difficulty following diet (81.4%) and fluid (74.6%) restrictions. Younger male patients and smokers were at highest risk for non-adherence. Higher levels of interdialysis weight gain were associated with nonadherence.

CONCLUSIONS

The findings indicate the need to continue to monitor and study hemodialysis patients' adherence behavior longitudinally and to design interventions to enhance adherence.

Disablement and rehabilitation in end-stage renal disease

Patients with end-stage renal disease (ESRD) are encumbered by disabilities in spite of advances in medical treatments. Research shows that exercise training is one way to improve physical work capacity and reduce functional limitations that impede role behaviors, such as shopping, personal care, homemaking, and yard maintenance. However, exercise training does not ameliorate some of the psychosocial and environmental factors that exacerbate disabilities for patients with ESRD. A disability process model described in this review illustrates that disability prevention may be more effective if exercise rehabilitation is integrated with self-management education. Research is needed to delineate which disabilities in patients with ESRD are a product of psychosocial factors and physical environments. Once identified, those disability risk factors that are amenable to change can guide the development of tailored rehabilitation interventions.

Diet monotony as a correlate of poor nutritional intake among hemodialysis patients

OBJECTIVE

Nutritional guidelines recommend eating a variety of foods, yet the renal diet restricts the intake of many foods. Poor appetite, present in 10% to 30% of hemodialysis patients, further narrows the range of foods consumed. We sought to determine the relationship between diet monotony and nutritional intake in patients on chronic hemodialysis.

DESIGN

Cross-sectional study.

SETTING

Eight freestanding hemodialysis units in northeast Ohio.

SUBJECTS

Forty-eight randomly selected hemodialysis patients.

INTERVENTION

We used the Block-National Cancer Institute questionnaire to obtain a detailed food frequency and also asked patients to rate their appetite for 10 specific high-protein foods.

OUTCOME MEASURE

We adapted the Herfindahl index (a measure of hospital market concentration) to calculate a diet monotony index and then examined the relationship between monotony index and energy and protein intake.

RESULTS

When stratified into tertiles by monotony index, patients with the most varied diets had the highest energy (33 kcal/kg/d) and protein (1.35 g/kg/d) intake, whereas patients with the most monotonous diets had the lowest energy (21 kcal/kg/d) and protein (0.83 g/kg/d) intake. A 5-point increase in monotony index was independently associated with a 10 kcal/kg/d decrease in energy intake (P = .004) and a 0.43 g/kg/d decrease in protein intake (P = .006) after adjustment for patient demographic and medical characteristics. Patients with the most monotonous diets reported a good appetite for an average of 3.1 high-protein foods that they were eating less than once per week.

CONCLUSION

Diet monotony strongly correlates with nutritional intake. However, patients with monotonous diets have a good appetite for several high-protein foods that they are not eating. Helping patients to identify and increase the intake of these foods may both enhance diet variety and improve nutritional status.

A controlled trial of intermittent enteral nutrient supplementation in maintenance hemodialysis patients

OBJECTIVE

This controlled trial was undertaken to evaluate the benefits of short-term enteral nutrient supplementation in maintenance hemodialysis (MHD) patients using a high-calorie and high-protein blend formula (low-cost home-prepared [HP] blend or a commercially available supplement) and to study its effect on selected parameters of nutritional status. The acceptability and palatability of the HP blend formula, ease of use, and cost were also assessed in comparison with the commercial nutritional supplement (CNS).

DESIGN

Randomized controlled trial.

SETTING

Hemodialysis (HD) unit of a tertiary referral care hospital in Southern India.

PATIENTS

Nondiabetic adult MHD patients with no intercurrent illness, on regular thrice weekly MHD for at least 1 month before recruitment, with a body mass index (BMI) <20 and a serum albumin level of <4.0 g/dL. Patients were randomized into control group and experimental group, the latter in turn to recieve either CNS or HP blend.

INTERVENTION

The control group received appropriate monitoring, including dietary recall and counselling for the prescribed diet (protein intake of 1.2 g/kgIBW/d and energy of 35 to 45 kcal/kgIBW/d) but no specific post-HD supplement. Patients in the supplement group received the respective supplement post-HD (providing 500 kcal and 15 g protein) for 1 month in addition to the monitored diet prescription.

MAIN OUTCOME MEASURES

(1) Nutritional status parameters, BMI and serum albumin; (2) functional status on a 10-point Karnofsky scale; (3) adverse metabolic effects, hyperphosphatemia at start and end of study; and (4) subjective scoring for appetite, and acceptability of and tolerance to supplement.

RESULTS

Both groups showed an improvement in dry weight and BMI. In addition, the supplement group showed a significant increase in serum albumin level and functional scoring. Mild hyperphosphatemia occurred in the supplement group. An increase in baseline food intake was seen in the control group, but not in the supplemented group. No intolerance was reported to either supplement.

CONCLUSION

Enteral nutrient supplementation was shown to bring about a significant improvement in serum albumin level even in a short-term study. Use of an HP supplement was beneficial, acceptable, and inexpensive.

Adequate self-care of dialysed patients: a review of the literature

The purpose of this article is to clarify the concept: 'adequate self-care of patients treated with hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD)'. This was done by the specification of Orem's general definition of self-care and a review of the literature. Adequate self-care behaviours for preventing and regulating pathological processes and related disabilities e.g. following dialysis and medication prescriptions as well as diet and fluid regimens are well documented. Adequate self-care behaviours aimed to promote personal well-being or development are less well documented. The authors suggest that use of the concept of adequate self-care would enlarge the scope of the disease management of HD and CAPD patients. Further research should focus on systematically investigating self-care activities of dialysed patients and their contribution to health and quality of life outcomes.

Improving hemodialysis patient outcomes: a step-by-step approach

Hemodialysis patient outcomes are often suboptimal, with one-sixth of patients receiving an inadequate dialysis dose, one-fourth using catheters for vascular access, and more than one-half being malnourished. This review describes a four-step approach for improving dialysis patient outcomes. First, select an outcome to improve. This can be a global outcome such as mortality, morbidity, quality of life, or health care costs or an intermediate outcome (such as dialysis dose) that has a demonstrated link with a global outcome. Second, determine barriers to optimal outcomes. Both patient factors (such as noncompliance) and provider factors (such as the process of care) may act as barriers. Third, intervene on specific barriers. Interventions may involve providing medical or surgical treatment, changing patient or provider behavior, or modifying the system of care. Fourth, disseminate the intervention to other settings. "Early adopters" (those who quickly adopt an innovation) and "opinion leaders" (well-respected local physicians) are especially influential in determining the rate of dissemination. By using this approach, physicians can move from helping an individual patient to improving the outcomes of many patients.

The dialysis diet and fluid non-adherence questionnaire: validity testing of a self-report instrument for clinical practice

This study evaluated the validity of the dialysis diet and fluid non-adherence questionnaire (DDFQ) as a self-report instrument for clinical practice. The DDFQ was designed to measure non-adherence behaviour with diet and fluid guidelines in patients treated with hospital-based haemodialysis in Flanders (Belgium). In a multicentre cross-sectional study design, 564 patients from 10 dialysis centres in Flanders completed the DDFQ Criterion and construct validity of the instrument were substantiated using correlation techniques between the DDFQ and biochemical and biological ratings of non-adherence. The results of this study suggest that the DDFQ is a valid self-report instrument to assess non-adherence behaviour in haemodialysis patients in Flanders and probably also in other cultures.

Can a nutrition intervention improve albumin levels among hemodialysis patients? A pilot study

OBJECTIVE

To determine the effect of a tailored intervention on albumin levels among hemodialysis patients.

DESIGN

Randomized controlled trial.

SETTING

Eight freestanding chronic hemodialysis units in northeast Ohio.

SUBJECTS

Eighty-three randomly selected adult patients who had been on dialysis for at least 6 months and had a mean albumin <3.7 g/dL (bromcresol green method) or <3.4 g/dL (bromcresol purple method) for the last 3 months. To better elucidate the feasibility and outcomes of the intervention, we selected more intervention than control patients.

INTERVENTION

Dietitians of the 52 intervention patients determined whether any of the following potential barriers to adequate protein nutrition were present for each patient: (1) poor knowledge of protein-containing foods, (2) poor appetite, (3) needing help shopping or cooking, (4) low fluid intake, and (5) inadequate dialysis. Depending on the specific barriers present, the dietitians (1) educated patients on protein-containing foods, (2) recommended snacks for which patients had preserved appetite, (3) helped set up social supports, (4) provided recommendations on fluid intake, and/or (5) arranged for improved dialysis. Dietitians of the 31 control patients continued to provide usual care.

MAIN OUTCOME MEASURES

Change in albumin after 6 months, stratified as minimal change (less than.25 g/dL increase or decrease), moderate improvement (.25 to.49 g/dL increase), and large improvement (increase of .50 g/dL or more). To examine the role of inflammatory states, we also determined serum C-reactive protein levels at the beginning and end of the trial.

RESULTS

Among intervention patients, 29% had a minimal change in albumin, 44% had a moderate improvement, and 27% had a large improvement. Among control patients, 74% had a minimal change in albumin, 19% had a moderate improvement, and 6% had a large improvement (P <.001 for comparison of intervention and control subjects). About 60% of subjects had high baseline C-reactive protein levels (> 10 mg/L). However, there was little relationship between change in albumin and either baseline C-reactive protein levels or changes in C-reactive protein levels (P = .83).

CONCLUSION

A nutrition intervention tailored to patient-specific barriers resulted in improved albumin levels even among patients with high C-reactive protein levels. Further work is needed to refine and test this intervention on a larger sample.

Outcomes of renal replacement therapy among blacks and women

The outcomes of renal replacement therapy differ dramatically by race and gender. Compared with white patients, black patients have poorer outcomes in five clinical parameters (anemia, hypertension, vascular access, adequacy of dialysis, compliance), employment, and access to transplantation. Compared with males, females have poorer outcomes in hospitalization, three clinical parameters (anemia, vascular access, nutrition), quality of life, and access to transplantation. Despite several poorer intermediate outcomes, blacks and women do better than whites and men in survival. Eliminating racial and gender differences in outcomes of renal replacement therapy requires that we (1) become aware of such differences, (2) determine barriers to optimal outcomes, and (3) develop interventions to overcome these barriers. This approach can lead to improved outcomes not just among blacks and women but among all renal patients. Examining racial and gender differences can also lead to an increased understanding of renal disease.

Correlates of poor appetite among hemodialysis patients

OBJECTIVE

Poor appetite is an important barrier to adequate nutrition among hemodialysis patients. We sought to determine the relationship between overall appetite and (1) patient demographic and medical characteristics and (2) appetite for specific foods.

DESIGN

Cross-sectional study.

SETTING

All 22 chronic hemodialysis units in northeast Ohio.

PATIENTS

Two hundred ninety-eight randomly selected patents.

INTERVENTION

Interview and chart abstraction.

MAIN OUTCOME MEASURE

Overall patient appetite.

RESULTS

Of all patients, 12% reported poor overall appetite, 20% reported fair appetite, and 69% reported good appetite. There was no relationship between overall appetite and patient demographic (age, gender, race, education, health insurance) or medical (cause of renal failure, years on dialysis, number of comorbid conditions, Kt/V) characteristics. There was little relationship between overall appetite and appetite for 20 specific foods. Of 34 patients with poor overall appetite, 29 (85%) identified at least three specific protein foods for which they had good appetite and 28 (82%) identified at least three nonprotein foods for which they had good appetite.

CONCLUSION

Poor overall appetite is not associated with patient characteristics or appetite for specific foods. Most patients with poor overall appetite have good appetite for several specific foods. Helping patients increase the intake of these foods may be beneficial in improving nutritional status.