Understanding chronic malnutrition in childhood and old age: role of energy balance research

Energy expenditure: how much does it matter in infant and pediatric chronic disorders?

A sound understanding of energy needs during chronic illness is necessary to avoid imbalances in energy intake and requirements. Failure to accurately estimate energy needs results in both underfeeding and overfeeding in chronically ill children. Suboptimal energy and protein intake may lead to deterioration in body composition, particularly lean body mass loss, which eventually impacts functional outcomes in these vulnerable groups. Furthermore, infants and children with chronic illnesses have a high prevalence of malnutrition and can ill afford further nutritional deterioration from suboptimal nutrient delivery. On the other hand, unintended delivery of excessive energy in patients with chronic respiratory insufficiency results in increased respiratory burden and poor outcomes. Hence, awareness of the energy requirements and attention to energy and protein balance are important when caring for children with chronic illnesses. The basic concepts of the metabolic stress response, measurement of energy expenditure, and the impact of energy imbalance on clinical outcomes in children with chronic illness are reviewed.

Determinants of foodservice satisfaction for patients in geriatrics/rehabilitation and residents in residential aged care

BACKGROUND

Poor satisfaction with institutional food is a significant moderator of food intake in geriatrics/rehabilitation and residential aged care.

PURPOSE

To quantify the relationship between foodservice satisfaction, foodservice characteristics, demographic and contextual variables in geriatrics/rehabilitation and residential aged care.

METHODS

The Resident Foodservice Satisfaction Questionnaire was administered to 103 patients of 2 geriatrics/rehabilitation units and 210 residents of nine residential aged care facilities in Brisbane, Australia. Ordered probit regression analysis measured the association of age, gender, ethnicity and appetite, timing and amount of meal choice, menu selectivity, menu cycle, production system, meal delivery system and therapeutic diets with foodservice satisfaction.

RESULTS

Patient and resident appetite (P < 0.01), the amount and timing of meal choice (P < 0.01), self-rated health (P < 0.01), accommodation style (P < 0.05) and age (P < 0.10) significantly moderated foodservice satisfaction. High protein/high energy therapeutic diets (P < 0.01), foodservice production (P < 0.01) and delivery systems (P > 0.01) were significant moderators for those with 'fair' self-rated health.

CONCLUSIONS

Patient and resident characteristics and structural and systems-related foodservice variables were more important for influencing foodservice satisfaction than characteristics of food quality. The results suggest modifications to current menu planning and foodservice delivery methods: reducing the time-lapse between meal choice and consumption, augmenting the number of meals at which choice is offered, and revising food production and delivery systems.It is important that residents in poorer health who are a high risk of under-nutrition are provided with sufficient high protein/high energy therapeutic diets. Diets that restrict macro- and micro-nutrients should be minimized for all patients and residents.

The association between food insecurity and inflammation in the US adult population

OBJECTIVES

To expand the understanding of potential pathways through which food insecurity is associated with adverse health outcomes, we investigated whether food insecurity is associated with nutritional levels, inflammatory response, and altered immune function.

METHODS

We performed a cross-sectional analysis of the National Health and Nutrition Examination Survey (1999-2006) with 12,191 participants. We assessed food insecurity using the US Department of Agriculture food security scale module and measured clinical biomarkers from blood samples obtained during participants' visits to mobile examination centers.

RESULTS

Of the study population, 21.5% was food insecure. Food insecurity was associated with higher levels of C-reactive protein (adjusted odds ratio [AOR]=1.21; 95% confidence interval [CI]=1.04, 1.40) and of white blood cell count (AOR=1.36; 95% CI=1.11, 1.67). White blood cell count partly mediated the association between food insecurity and C-reactive protein.

CONCLUSIONS

These findings show that food insecurity is associated with increased inflammation, a correlate of chronic diseases. Immune response also appears to be a potential mediator in this pathway.

Pathophysiological changes that affect drug disposition in protein-energy malnourished children

Protein-energy malnutrition (PEM) is a major public health problem affecting a high proportion of infants and older children world-wide and accounts for a high childhood morbidity and mortality in the developing countries. The epidemiology of PEM has been extensively studied globally and management guidelines formulated by the World Health Organization (WHO). A wide spectrum of infections such as measles, malaria, acute respiratory tract infection, intestinal parasitosis, tuberculosis and HIV/AIDS may complicate PEM with two or more infections co-existing. Thus, numerous drugs may be required to treat the patients. In-spite of abundant literature on the epidemiology and management of PEM, focus on metabolism and therapeutic drug monitoring is lacking. A sound knowledge of pathophysiology of PEM and pharmacology of the drugs frequently used for their treatment is required for safe and rational treatment. In this review, we discuss the pathophysiological changes in children with PEM that may affect the disposition of drugs frequently used for their treatment. This review has established abnormal disposition of drugs in children with PEM that may require dosage modification. However, the relevance of these abnormalities to the clinical management of PEM remains inconclusive. At present, there are no good indications for drug dosage modification in PEM; but for drug safety purposes, further studies are required to accurately determine dosages of drugs frequently used for children with PEM.

Body composition in childhood: effects of normal growth and disease

Body composition in children is of increasing interest within the contexts of childhood obesity, clinical management of patients and nutritional programming as a pathway to adult disease. Energy imbalance appears to be common in many disease states; however, body composition is not routinely measured in patients. Traditionally, clinical interest has focused on growth or nutritional status, whereas more recent studies have quantified fat mass and lean mass. The human body changes in proportions and chemical composition during childhood and adolescence. Most of the weight gain comprises lean mass rather than fat. In general, interest has focused on percentage fat, and less attention has been paid to the way in which lean mass varies within and between individuals. In the general population secular trends in BMI have been widely reported, indicating increasing levels of childhood obesity, which have been linked to reduced physical activity. However, lower activity levels may potentially lead not only to increased fatness, but also to reduced lean mass. This issue merits further investigation. Diseases have multiple effects on body composition and may influence fat-free mass and/or fat mass. In some diseases both components change in the same direction, whereas in other diseases, the changes are contradictory and may be concealed by relatively normal weight. Improved techniques are required for clinical evaluations. Both higher fatness and reduced lean mass may represent pathways to an increased risk of adult disease.

Energy balance and its measurement in childhood disease

Under and overweight, usually secondary to energy imbalance, are common complications of childhood chronic disease. A simple energy balance paradigm has been helpful in understanding the etiology of underweight and overweight in chronic disease, including malignant disease, particularly when measurements of total energy expenditure have been made using the doubly labeled water method. Measurements of energy intake are usually insufficiently accurate and precise to be informative, and measurements of energy expended at rest alone provide an incomplete and potentially misleading assessment of energy expenditure and the causes of energy imbalance. In some diseases, such as acute lymphoblastic leukemia, the natural history and etiology of energy imbalance are now particularly well understood. Recent improvements in our understanding of etiology should lead to improved strategies for the prevention and treatment of underweight and overweight in chronic disease. In some diseases, cachectic processes drive the development of underweight: these are partly independent of energy balance, and strategies for prevention and treatment may require approaches aimed at modifying the cachectic process rather than attempting to modify energy balance directly.

Epidemiological and physiological approaches to understanding the etiology of pediatric obesity: finding the needle in the haystack

Recent increases in the prevalence of childhood obesity have created an urgent need for preventive strategies, but such strategies in turn depend on an improved understanding of the etiology of pediatric obesity. There is a dearth of evidence of the cause of pediatric obesity at present, with much of the literature of limited quality, inconclusive, and contradictory. The present review highlights the paradox of energy imbalance-its apparent simplicity but actual complexity-and the difficulties in etiologic research that arise from this complexity. The review identifies a number of emerging problems for etiologic studies. The review also makes a number of proposals that might improve future etiologic studies and provides a framework for integrating the diverse body of evidence of etiology that will become available in future. Gathering improved evidence of etiology, and then integrating and interpreting it, will take many years. In the meantime, an emphasis on developing more effective preventive interventions is necessary.

Physical activity interventions in the prevention and treatment of paediatric obesity: systematic review and critical appraisal

Interventions for prevention and treatment of childhood obesity typically target increases in physical activity and, more recently, reductions in physical inactivity (sedentary behaviour such as television viewing). However, the evidence base for such strategies is extremely limited. The main aim of the present review was to update the systematic review and critical appraisal of evidence in the light of the recent rapid expansion of research in this area. Randomised controlled trials (RCT) that targeted activity or inactivity, that followed up children or adolescents for at least 1 year and that included an objective weight-related outcome measure were included. Trials were appraised using previously published criteria (Harbour & Miller, 2001), and literature search strategies described previously (Reilly et al. 2002) were updated to May 2002. A total of four new RCT, two new systematic reviews and one meta-analysis were identified. The evidence base has increased markedly since the completion of earlier reviews, although high-quality evidence is still lacking. The evidence on childhood obesity prevention is not encouraging, although promising targets for prevention are now clear, notably reduction in sedentary behaviour. There is stronger evidence that targeting activity and/or inactivity might be effective in paediatric obesity treatment, but doubts as to the generalisability of existing interventions, and the clinical relevance of the interventions is unclear. Further research in settings outside the USA is urgently needed, and two ongoing RCT in Scotland are summarised.

Assessment of obesity status in outpatients from three disease states

AIM

To assess obesity status in patients with cystic fibrosis (CF), human immunodeficiency virus (HIV) and various metabolic disorders (MD), through comparison against a) UK reference data and b) contemporary healthy children.

METHODS

Weight, height, waist circumference (WC), and triceps (TRI) and sub-scapular (SUBS) skinfold thickness were measured in a total of 57 healthy, 49 HIV, 68 MD and 49 CF children. Using published reference data, standard deviation scores (SDS) were calculated.

RESULTS

CF patients had weight, height and BMI SDS significantly below zero. MD patients had height SDS significantly below, and BMI SDS significantly above, zero. Healthy children had BMI SDS significantly above zero. In all three patient groups and healthy children, TRI and WC SDS were significantly above zero. SUBS SDS was also significantly above zero in patients with MD and HIV. WC SDS was greater in patients than in healthy children, but only significantly so for the MD children.

CONCLUSION

In all three patient groups, even those associated with reduced stature or reduced weight, indices of fatness were significantly increased relative to reference data. The tendency to central fatness was evident in healthy children, but was more extreme in patients, especially those with MD.

The utility of genetically altered mouse models for nutrition and cancer chemoprevention research

The development of effective cancer preventive interventions is being enhanced by the use of relevant animal models to confirm, refine, and extend potential leads from clinical and epidemiologic studies. In particular, genetically altered mice, with specific cancer-related genes modulated, are providing powerful tools for studying carcinogenesis, as well as important conduits for translating basic research findings from the laboratory bench to the bedside. This review explores the utility of genetically altered mice for developing cancer preventive strategies that can offset increased cancer susceptibility resulting from specific genetic lesions. Examples will focus on preventing cancer by dietary interventions, particularly obesity prevention/energy balance modulation, as well as chemoprevention, in mice with alterations in genes such as the p53 or Apc tumor suppressors, components of the ErbB pathway, and other pathways frequently altered in human cancer.

Malnutrition and health in developing countries

Malnutrition, with its 2 constituents of protein-energy malnutrition and micronutrient deficiencies, continues to be a major health burden in developing countries. It is globally the most important risk factor for illness and death, with hundreds of millions of pregnant women and young children particularly affected. Apart from marasmus and kwashiorkor (the 2 forms of protein- energy malnutrition), deficiencies in iron, iodine, vitamin A and zinc are the main manifestations of malnutrition in developing countries. In these communities, a high prevalence of poor diet and infectious disease regularly unites into a vicious circle. Although treatment protocols for severe malnutrition have in recent years become more efficient, most patients (especially in rural areas) have little or no access to formal health services and are never seen in such settings. Interventions to prevent protein- energy malnutrition range from promoting breast-feeding to food supplementation schemes, whereas micronutrient deficiencies would best be addressed through food-based strategies such as dietary diversification through home gardens and small livestock. The fortification of salt with iodine has been a global success story, but other micronutrient supplementation schemes have yet to reach vulnerable populations sufficiently. To be effective, all such interventions require accompanying nutrition-education campaigns and health interventions. To achieve the hunger- and malnutrition-related Millennium Development Goals, we need to address poverty, which is clearly associated with the insecure supply of food and nutrition.

Effects of energy balance on cancer in genetically altered mice

Evidence has accumulated from laboratory-based animal experiments and population-based human epidemiological studies that lifestyle factors that affect energy balance, such as caloric intake, nutritional status, and exercise, act in concert with genetic susceptibility to influence cancer development and progression. The use of animal models with specific genetic alterations, in combination with lifestyle modifications that alter overall energy balance, has contributed to a greater understanding of the mechanistic changes occurring during carcinogenesis and to the identification of points of intervention. Studies in our laboratory focusing on the role of energy balance and genetic susceptibility in mice deficient in one (+/-) or both (-/-) alleles of the p53 tumor suppressor gene and mice with a mutant APC allele (APC(Min)) showed that calorie restriction decreases tumor burden, increases tumor latency, and decreases serum insulin-like growth factor (IGF)-1 and leptin levels. Data from our studies, combined with results from other animal and human studies, have established a role for IGF-1 in carcinogenesis. Studies using genetic models of cancer that have been interbred with mice with abnormal levels of IGF-1 will enable the examination of combined effects of energy balance and genetic alterations on the cancer process. Models that integrate lifestyle and genetic effects in a single system provide a physiologically intact system in which combination interventions and therapies for cancer prevention can be tested and validated, thus building a strong preclinical foundation that will inform the development of clinical trials and add perspective to epidemiological studies.

Oral supplements differing in fat and carbohydrate content: effect on the appetite and food intake of undernourished elderly patients

BACKGROUND & AIMS

Since fat, relative to other macronutrients, has low satiety and high energy density, it may have therapeutic application for supplementing energy intake. This study compared the effect of isoenergetic (1050 kJ) high fat or high carbohydrate oral supplements, given at breakfast, on the short-term appetite and energy intake in undernourished elderly subjects.

METHODS

Sixteen hospitalised, undernourished (body mass index: 20 +/- 3 kg/m2), elderly (77 +/- 8 yr) people were randomly allocated to a control or 1 of 2 supplement groups [fat: carbohydrate: protein (% energy) was 70:25:5 or 25:70:5]. In each group, energy intake (24-h food consumption) and appetite (visual analogue scales) were assessed over 3 consecutive days.

RESULTS

Mean energy intake significantly (P = 0.0035) increased following supplementation: high fat 6973 kJ/d, high carbohydrate 6906 kJ/d vs. control 6079 kJ/d but mean voluntary 24-h energy intake remained unaffected. Compared to controls, supplemented subjects experienced reduced hunger (P = 0.07) between breakfast and lunch, but showed no difference over the whole day (P = 0.55).

CONCLUSIONS

Under these study conditions a 1050 kJ oral supplement, irrespective of macronutrient composition, does not cause voluntary short-term energy intake compensation in undernourished elderly people.