The Sapienza count-down for a healthy and sustainable diet

Abstract

The prevalence of obesity and of other non-communicable diseases related to overnutrition is significantly increasing in the past few years. Policy makers are called to counteract this pandemic, orienting consumers towards a healthier and more sustainable diet. Most of the proposed initiatives are dedicated to the content of nutrients with "unfavourable" effects but, in fact, focusing the attention only or mainly on single foods or nutrients is not effective in decreasing the incidence/prevalence of non-communicable diseases. Whole dietary patterns play by far a more important role than specific dietary components in promoting health and modulating survival; and the adherence to eating patterns like the Mediterranean diet reduces the risk of non-communicable diseases. The challenge is therefore to be able to transmit information relating to a healthy eating pattern through positive messages in a few simple indications which in turn represent the nutritional, but also the socio-cultural, environmental and economic characteristics of a healthy and sustainable dietary model. The Mediterranean Diet is normally proposed through a graphic depiction that represents a pyramid which is a simple and effective representation but not of immediate impact. For this reason, we are proposing to adopt the "Sapienza Count-down for a Healthy and Sustainable Diet" that will integrate the pyramid with a more immediate approach.

AB0317 ADHERENCE TO MEDITERRANEAN DIET AND NUTRITIONAL STATE IN ITALIAN WOMEN WITH ISOLATED SJÖGREN’S SYNDROME

Background:

The Mediterranean Diet (MD) has anti-inflammatory and immunomodulatory effects1,2 suggesting a protective role in rheumatic diseases. There is limited knowledge about the eating habits and the nutritional state in patients with isolated Sjögren Syndrome (SS) living within the Mediterranean area.

Objectives:

assessment of adherence to the MD and analysis of the nutritional state in women with SS and their correlations with the clinical, laboratory and histological data of the disease.

Methods:

patients classified as isolated SS according to AECG criteria 20023 who had undergone to minor salivary gland biopsy during the previous twelve months were consecutively enrolled during follow-up visits. The adherence to the MD was assessed by the Med Diet (MDiet)4 which includes eleven groups of foods; to each group is assigned a value ranging between 0 and 5 based on the frequency of monthly intake. The total score spans from 0 (poor adherence) to 55 (maximum adherence). The level of physical activity was measured by the 6-minutes walking test (6MWT) and by the International Physical Activity Questionnaire (IPAQ). Systemic disease activity was evaluated with the EULAR SS disease activity index (ESSDAI); EULAR SS patient-reported index (ESSPRI) was calculated as well. A subgroup of patients was asked to fill a daily food diary processed with FOOD CONS software which allows to study in detail their eating habits. Nutritional state, muscle strength and basal metabolic rate were assessed. Alcoholism or drug abuse, diabetes mellitus, specific dietary models, treatment with drugs and/or food supplements with anti-inflammatory and/or antioxidant activity were considered exclusion criteria. Multivariate linear regression was performed with R project for Statistical Computing.

Results:

N= 40 N= 26Age, median (range) 53 (25-80) 33 (25-71)BMI, median (range) 21 (19-29.3) 25.1 (19-33.7)MedDiet score, median (range) 33 (26-43) 33 (23-40)ESSDAI, median (range) 2 (0-16) 1 (0-16)ESSPRI, median (range) 6 (0-8.6) 5.3 (1.6-9)ESSPRI dryness, median (range) 6 (0-10) 6 (2-10)Focus score, median (range) 2.5 (0-9.6) 1.7 (0.8-6.24)ASM kg, median (range) - 16.8 (13.3-21.7)IPAQ meters, median (range) - 1386 (99-11865)6MWT meters, median (range) - 595 (536-680)

BMI, body mass index; ASM appendicular skeletal mass; IPAQ International Physical Activity Questionnaire; 6MWT, six minute walking test.

MDiet was administered to 40 female SS outpatients. Even if not reaching significativity, patients with a higher focus score in their MSG have a lower value of MDiet score (p = 0.058, r = -1.00). The MDiet score is not associated with ESSDAI (p = 0.85, r 0.02), but only with lower serum levels of C3 (p = 0.004, r = - 0.08).

In 26 patients, daily food questionnaire shows that their diet consists of 43% of carbohydrates while fats represent 40% of total energy intake, the remaining 17% daily energy comes from proteins. Fat consumption is higher compared to the levels of energy and nutrient intake for the Italian population5. Six patients had a reduction in muscle mass; sarcopenia is not associated to ESSDAI (p = 0.610).The MDiet score and the amount eaten of polyunsaturated fatty acids (PUFA) were reduced in patients with high value of subscale dryness of ESSPRI (p = 0.057, r -1.21; p =0.610, r -1.00).

Conclusion:

This study highlights a lower degree of glandular lymphocytic infiltration (expressed as focus score) in minor salivary glands in patients following MD, so its anti-inflammatory role of seems to be confirmed. SS patients have an unbalanced diet because of a higher intake of fat foods, likely for their lubricating effect. Despite the absence of correlation with objective parameters, the increased dryness in patients with a reduced intake of PUFA arouses our interest in a future study including omega-3 supplementation.

References:

[1]Schwingshackl L et al., Nutr Metab Cardiovasc Dis 2014

[2]Mena MP et al., Am J Clin Nutr. 2009

[3]Vitali C et al, ARD 2002

[4]Panagiotakos D et al., J Med Food 2007

[5]LARN 2014

Disclosure of Interests:

None declared

Very-low-calorie ketogenic diet (VLCKD) in the management of metabolic diseases: systematic review and consensus statement from the Italian Society of Endocrinology (SIE)

BACKGROUND

Weight loss is a milestone in the prevention of chronic diseases associated with high morbility and mortality in industrialized countries. Very-low calorie ketogenic diets (VLCKDs) are increasingly used in clinical practice for weight loss and management of obesity-related comorbidities. Despite evidence on the clinical benefits of VLCKDs is rapidly emerging, some concern still exists about their potential risks and their use in the long-term, due to paucity of clinical studies. Notably, there is an important lack of guidelines on this topic, and the use and implementation of VLCKDs occurs vastly in the absence of clear evidence-based indications.

PURPOSE

We describe here the biochemistry, benefits and risks of VLCKDs, and provide recommendations on the correct use of this therapeutic approach for weight loss and management of metabolic diseases at different stages of life.

Are the therapeutic strategies in anorexia of ageing effective on nutritional status? A systematic review with meta-analysis

BACKGROUND

Anorexia of ageing (AA) may be considered as a risk factor for frailty and has an important impact on quality of life, morbidity and mortality.

METHODS

A systematic review and a meta-analysis were performed to summarise the results from several trials on the effectiveness of treatments in AA, as associated with depression, sensory impairment of taste and smell, decreased appetite or early satiety, and disability. Eligible studies were required to report baseline and follow-up values, the mean change (∆-change) from baseline, and/or the mean difference among intervention groups versus control group, concerning food intake (kcal/daily) and/or nutritional outcomes, such as body weight, body mass index, albumin and Mini Nutritional Assessment.

RESULTS

The systematic review included 20 papers based on different therapeutic approaches concerning food intake and/or nutritional outcomes. The results of the meta-analysis indicate that the interventions for AA have an important impact on body weight [+1.59 kg; 95% confidence interval (CI) = 1.48-+1.71 kg; P < 0.001) and on energy intake (+56.09 kcal; 95% CI = -54.05 to +166.25 kcal; P = 0.32). Regarding secondary outcomes, it was not possible to meta-analyse the limited amount of data availab le.

CONCLUSIONS

The different variants of AA need to be defined because diverse therapeutic approaches are available. A more precise definition of the functional impairments associated with AA may allow a more correct decision about the most appropriate therapy to be prescribed. Moreover, this may allow for a more effective performance of the different therapeutic approaches once they are better targeted to the different scenarios of AA.

Effects of an individualized home-based unsupervised aerobic training on body composition and physiological parameters in obese adults are independent of gender

PURPOSE

Evaluation of the effects of an individualized home-based unsupervised aerobic training on body composition, physical and physiological parameters in female and male obese adults.

METHODS

Two hundred and twenty obese adults (age 47.9 ± 12.4 years; BMI 38.0 ± 7.2 kg/m²) entered the 4-month training program. Body composition, physiological and functional capacities were assessed pre- and post-intervention. All subjects were requested to perform unsupervised aerobic training with the intensity based on heart rate, walking speed and OMNI-RPE score corresponding to the individual ventilatory threshold for at least 5 days/week.

RESULTS

After 4-month study period, 40% of patients completed the protocol, 24% had high compliance (HC) (exercise ≥ 3 days/week), while 16% had low compliance (LC) to exercise prescription (exercise < than 3 days/week). In HC group, a significant improvement of body composition variables after training was performed. Moreover, oxygen uptake and metabolic equivalent at peak significantly increased after training. Six-minute walking test (6MWT) distance significantly increased while heart rate during 6MWT was significantly lower after training. No significant differences were found in LC group between pre- and post-intervention in all variables. Interestingly, gender does not influence the effects of training.

CONCLUSIONS

Our results indicate that subjects, independent of gender, with high compliance to the aerobic training based on a new individualized method can achieve a significant reduction in weight loss and also an improvement in physical and physiological parameters. This innovative personalized prescription could be a valuable tool for exercise physiologist, endocrinologists, and nutritionists to approach and correct life style of obese subjects.

Does endogenous GLP-1 affect resting energy expenditure and fuel selection in overweight and obese adults?

PURPOSE

To investigate the association between fasting glucagon-like peptide 1 (GLP-1) levels and resting energy expenditure (REE), and respiratory quotient (RQ) in overweight and obese adults.

METHOD

Study participants were enrolled at the Dietetic and Metabolic Unit, University of Pavia, Italy. Inclusion criteria were age ≥ 25 and ≤ 45 years, and body mass index (BMI) ≥ 25 and ≤ 35 kg/m². Diabetic subjects were excluded. Body composition was measured by dual-energy X-ray absorptiometry. REE was evaluated using indirect calorimetry, and RQ was calculated from respiratory gas exchanges. Fasting GLP-1, glucose, insulin and free fatty acid (FFA) levels, and 24-h norepinephrine urinary excretion were measured. Homeostasis model assessments of insulin resistance (HOMA-IR) and beta-cell function (HOMA-β) were calculated.

RESULTS

Thirty-seven participants were included (age 43.4 ± 1.6 years; BMI 30.6 ± 0.5 kg/m²). REE was not associated with fasting GLP-1 levels (p = 0.98) after adjustment for age, sex, fat-free mass (FFM), and fat mass (FM). Similarly, no association was observed between RQ and GLP-1 levels (p = 0.95), after adjustment for age, sex, and body fat.

CONCLUSION

In adults subjects with increased adiposity fasting, GLP-1 levels do not seem to play a role in the regulation of energy metabolism and in fuel selection.

Validity of the Self- Mini Nutritional Assessment (Self- MNA) for the Evaluation of Nutritional Risk. A Cross- Sectional Study Conducted in General Practice

INTRODUCTION

Malnutrition is a frequent condition in the elderly especially in hospitals and in nursing homes, and even among the free-living elders the prevalence is not negligible (5-10%). Awareness towards malnutrition is still limited. The lack of time for nutritional assessment by the overcommitted healthcare personnel, including the general practitioners (GPs), may represent one possible explanation for limited recognition of malnutrition. Therefore, a self-administered instrument could be useful in raising alert on the GPs and allow early detection of malnutrition and early care provision. The aim of the present study was to analyze the validity of the Self-MNA that takes cue from the Mini Nutritional Assessment- Short Form (MNA-SF) and has been adapted to be self-administered by free-living elderly subjects.

METHODS

Participants were recruited from patients referring to the GP offices in Italy. Nutritional evaluation was performed through the administration of Full-MNA, MNA-SF and Self-MNA. The comorbidity level was assessed through the Cumulative Illness Rating Scale (CIRS). The level of difficulty in filling out the test was reported by the participants, and the time spent to complete the Self-MNA was also registered.

RESULTS

A total of 226 subjects, 125 women and 101 men (75.1 ±8 and 75.3 ± 8 years old, respectively; p=0.89) were enrolled, and 214 (94.7%) of them completed the Self-MNA. According with the Full-MNA test score, 8.4% of women and 3.5% of men were classified as malnourished, whereas 32.7% of women and 31.4% of men were at risk of malnutrition. Agreement between Self-MNA and Full-MNA, and Self-MNA vs. MNA-SF was classified as "moderate" (k = 0.476 and 0.496 respectively; p < 0.001). Self-MNA showed a fair predictive value compared to the Full-MNA and MNA-SF tests (76.6 and 79.9%, respectively) with a barely adequate sensitivity (70.9 and 75.4%, respectively). The analysis of the characteristics of FN (false negative: subjects who were considered at risk of malnutrition or malnourished at Full-MNA but not at Self-MNA) showed that the clinical and functional aspects of these subjects (age, comorbidity and severity, time necessary to complete the Self-MNA, decrease in food intake, severe illness in the past 3 months, dementia and depression, fluid intake, need for feeding assistance, arm and calf circumferences) were very similar to the characteristics of true positive subjects. Patients required 6.7 ± 4.5 minutes to complete the test and 25 subjects (11.7%) needed more than 10 minutes, up to a maximum of 30 minutes. Patients who stated a greater difficulty were older (79.8 ± 7 vs. 73.5 ± 7 years; p<0.001), they were more «malnourished» at Full-MNA (10.7 vs. 1,7%; p= 0.006) and clinical status was characterized by a higher severity index (1.72 ± 0.6 vs. 1.41 ± 0.4; p= 0.008).

CONCLUSION

In the present study we investigated the validity of the Self-MNA in a sample of free-living elderly subjects. The results obtained confirm the validity of the test that may represent a useful tool for the GPs, although some important limitations need to be considered, limiting its use in clinical practice.

The New Modern Mediterranean Diet Italian Pyramid

BACKGROUND

Epidemiological studies have established the health benefits associated with the adherence to the MD (Mediterranean Diet), mainly in relation to reducing the risk of developing the non communicable diseases. The MD is a sustainable diet model that respects the environment, promotes the bio-diversity, the local cultural heritages, the social interaction and economic aspects.

METHODS

The pyramid is a graphical representation designed to represent the frequencies of consumption and portion sizes of each food according to the Mediterranean model and tradition. The pyramid was developed taking into account the LARN (Reference Intake of nutrients and energy for Italian Population) and the Italian Guidelines for a healthy diet.

RESULTS

The frequency of consumption and the portion size recommended are located at the different level of the pyramid. At the base of the pyramid there are the foods that should be consumed every meal and some concepts typical of the Mediterranean culture. In the middle there are foods that should be consumed daily and at the top of the pyramid the foods consumed on a weekly basis.

CONCLUSIONS

The new modern MD Italian Pyramid is an important tool to promote the MD and improve the adherence to the MD dietary pattern.

Circulating SIRT1 inversely correlates with epicardial fat thickness in patients with obesity

BACKGROUND AND AIM

Obesity is increasing worldwide and is related to undesirable cardiovascular outcomes. Epicardial fat (EF), the heart visceral fat depot, increases with obesity and correlates with cardiovascular risk. SIRT1, an enzyme regulating metabolic circuits linked with obesity, has a cardioprotective effect and is a predictor of cardiovascular events. We aimed to assess the relationship of EF thickness (EFT) with circulating SIRT1 in patients with obesity.

METHODS AND RESULTS

Sixty-two patients affected by obesity and 23 lean controls were studied. Plasma SIRT1 concentration was determined by enzyme-linked immunosorbent assay (ELISA). EFT was measured by echocardiography. Body mass index (BMI), waist circumference, heart rate (HR), blood pressure, and laboratory findings (fasting glucose, insulin, HbA1c, cholesterol, and triglycerides) were assessed. SIRT1 was significantly lower (P = 0.002) and EFT was higher (P < 0.0001) in patients with obesity compared with lean controls. SIRT1 showed a negative correlation with EFT and HR in the obesity group (ρ = -0.350, P = 0.005; ρ = -0.303, P = 0.008, respectively). After adjustment for obesity-correlated variables, multiple linear regression analysis showed that EFT remained the best correlate of SIRT1 (β = -0.352, P = 0.016).

CONCLUSIONS

Circulating SIRT1 correlates with the visceral fat content of the heart. Serum SIRT1 levels might provide additional information for risk assessment of coronary artery disease in patients with obesity.

Energy drink consumption in Italian university students: food habits and lifestyle

OBJECTIVES

The aim of this study was to investigate the consumption of ED (Energy drink) among young people, both alone and in association with alcohol, as well as the food habits and lifestyle of ED consumers.

MATERIALS AND METHODS

An anonymous closed-ended questionnaire, was administered to a sample of students. The questionnaire is composed of 30 questions with multiple answers. The students, who come from different regions in Italy, were enrolled at two Italian Universities: Rome and Cagliari. T-test and the analysis of variance (ANOVA) were performed and chi-square test was used to compare observed and expected frequencies.

RESULTS

The sample was composed by 618 females and 389 males and revealed statistically significant differences related to the gender in terms of lifestyle and food habits. About 2/3 of the sample has consumed ED at least once. ED consumers in the total sample accounted for 655 students (65,0%). The 41.3% of the females and the 58,8% of males were ED consumers. Habitual consumers represent the 15,8% of the ED consumers, while occasional consumers the 84,2 %. Habitual and occasional consumers show statistically significant differences both for the lifestyle and the food habits. The 72.1% of ED consumers drink ED in association with alcohol (ED-based cocktails).

CONCLUSIONS

Our results suggest that would be recommended to inform consumers about the side effects related to an excessive use of ED, particularly when combined with alcohol: indeed, this combination is known to have adverse effects on the cardiovascular system, on the nervous system, leading in particular to sleeping disorders.

Sarcopenic Obesity and Metabolic Syndrome in Adult Caucasian Subjects

OBJECTIVES

Recently metabolic aspects linked to sarcopenic obesity (SO) were investigated. Extant studies involved especially older people from Asian or White-mixed American cohorts.

THE AIMS OF OUR STUDY WERE

to explore the prevalence of sarcopenia in Caucasian adult obese subjects using two different indices of sarcopenia, and to investigate the relationship among SO, metabolic syndrome (MS), inflammation, and serum albumin concentrations.

DESIGN

Cross- sectional study.

SUBJECTS/METHODS

The study was performed from 2011 to 2014 in a hospitalized care setting. Inclusion criteria were: age>18 and <65 years, BMI≥30 Kg/m2. Fat mass (FM) and fat-free mass (FFM) were assessed by DXA. Appendicular skeletal muscle mass (ASMM) was calculated. Sarcopenia was defined as ASMM/height2 or ASMM/weight <2SD than the sex-specific mean of a young population. The cutoffs were ASMM/h2<6.54 Kg/m2 for men and 4.82 Kg/m2 for women, and ASMM/weight<0.2827 for men and 0.2347 for women. ISI-Matsuda was calculated. MS was diagnosed (NCEP-ATPIII).

RESULTS

727 subjects (age: 45.72±13.56 years, BMI: 37.74±5.82 kg/m2) were enrolled. The prevalence of SO was 1.0% or 34.8% in men and 0.6% or 50.1% in women, using ASMM/height2 ratio or ASMM/weight. Subjects with SO based on ASMM/height2 were scarce, only data relying on ASMM/weight were considered. Subjects with SO had higher BMI, waist circumference, FM, and lower FFM and ASMM than nonsarcopenic obese individuals (all p<0.05). ISI-Matsuda was lower and hs-CRP levels were higher in subjects with SO (all p<0.05). MS was more prevalent in subjects with SO than nonsarcopenic obese subjects (47.6% vs 34.3%, p<0.001). ASMM/weight was decreased in subjects with MS (0.2522±0.0410 vs 0.2423±0.0352, p=0.001).

CONCLUSION

SO is associated with MS and low- grade inflammation in adult Caucasian subjects. Metabolic profile evaluation should be recommended in subjects with SO.

Impact of diet and nutraceutical supplementation on inflammation in elderly people. Results from the RISTOMED study, an open-label randomized control trial

BACKGROUND & AIMS

Eating habits may influence the life span and the quality of ageing process by modulating inflammation. The RISTOMED project was developed to provide a personalized and balanced diet, enriched with or without nutraceutical compounds, to decrease and prevent inflammageing, oxidative stress and gut microbiota alteration in healthy elderly people. This paper focused on the effect on inflammation and metabolism markers after 56 days of RISTOMED diet alone or supplementation with three nutraceutical compounds.

METHODS

A cohort of 125 healthy elderly subjects was recruited and randomized into 4 arms (Arm A, RISTOMED diet; Arm B, RISTOMED diet plus VSL#3 probiotic blend; Arm C, RISTOMED diet plus AISA d-Limonene; Arm D, RISTOMED diet plus Argan oil). Inflammatory and metabolism parameters as well as the ratio between Clostridium cluster IV and Bifidobacteria (CL/B) were collected before and after 56 days of dietary intervention, and their evolution compared among the arms. Moreover, participants were subdivided according to their baseline inflammatory parameters (erythrocytes sedimentation rate (ESR), C-Reactive Protein, fibrinogen, Tumor Necrosis Factor-alfa (TNF-α), and Interleukin 6) in two clusters with low or medium-high level of inflammation. The evolution of the measured parameters was then examined separately in each cluster.

RESULTS

Overall, RISTOMED diet alone or with each nutraceutical supplementation significantly decreased ESR. RISTOMED diet supplemented with d-Limonene resulted in a decrease in fibrinogen, glucose, insulin levels and HOMA-IR. The most beneficial effects were observed in subjects with a medium-high inflammatory status who received RISTOMED diet with AISA d-Limonene supplementation. Moreover, RISTOMED diet associated with VSL#3 probiotic blend induced a decrease in the CL/B ratio.

CONCLUSIONS

Overall, this study emphasizes the beneficial anti-inflammageing effect of RISTOMED diet supplemented with nutraceuticals to control the inflammatory status of elderly individuals.

Lean mass in obese adult subjects correlates with higher levels of vitamin D, insulin sensitivity and lower inflammation

AIM

Several chronic metabolic alterations are present in obese subjects. While it is well known about the detrimental effect of abdominal adipose tissue on chronic metabolic clinical condition, less is known on the role of lean mass in obese subjects. Thus, the aim of our study was to evaluate the potential correlation of muscle mass, metabolic condition and inflammation status in obese individuals.

METHODS

The study included 426 obese subjects (86 men and 340 female; mean age 44.8 ± 14 years; BMI: 34.9 ± 6.1 kg/m(2)). Exclusion criteria were chronic medical conditions or use of medications affecting bone metabolism, alterations of hormonal and nutritional status, vitamin D supplementation, recent weight loss and prior bariatric surgery. Patients underwent measurements of bone mineral density (lumbar and hip) and body composition (lean mass, total and trunk fat mass) by dual X-ray absorptiometry and were evaluated for hormonal and metabolic profile and inflammatory markers.

RESULTS

Higher lean body mass (LM%) was inversely correlated with homeostasis model assessment of insulin resistance (p < 0.0091; r(2) 0.03938) and associated with lower fibrinogen levels (p < 0.0001; r(2) 0.1263). Interestingly, in obese subjects, LM% was associated with higher levels of vitamin D (p < 0.0001, r(2) 0.1140), osteocalcin (p < 0.0001, r(2) 0.2401) and insulin-like growth factor-1 (IGF-1) (p < 0.0002, r(2) 0.1367).

CONCLUSION

Our results show for the first time that in obese patients, higher amounts of lean mass are directly linked to a lower inflammatory profile and to better insulin sensitivity, but also to the presence of higher level of vitamin D and IGF-1. Moreover, these data suggest that higher levels of lean mass in obese people correlate with a better metabolic profile and, thus, strongly suggest the need to develop programs to facilitate an increase in physical activity in obese people.

The yogurt amino acid profile's variation during the shelf-life

OBJECTIVE

To analyze the yogurt amino acid profile starting from marketing through the whole shelf-life. The evaluation of the proteolytic activity of Lactobacillus delbrueckii subsp. bulgaricus and Streptococcus salivarius subsp. thermophilus, allows to deduce their vitality during the shelf-life period and within 45 days.

METHODS

Three types of full fats yogurts have been analyzed (a) natural white (b) sweet white and (c) whole fruit - in two stages: t0 (first day of shelf-life) and t1 (end of shelf-life). The proteins have been analyzed by the Kjeldahl method and the amino acid profile by HPLC.

RESULTS

In natural yogurt a significant increase of the amount of free amino acids has been observed during the period of shelf-life (97%). In the sweetened full fats and fruit yogurt, instead, there is a lower increase of respectively 33% and 39%

CONCLUSIONS

In whole milk natural yogurt, based on our data, the proteolytic activity seems to persist during the entire period of the shelf-life and this can be considered an index of bacterial survival, especially of Lactobacillus delbrueckii subsp. bulgaricus during the marketing process.

Assessing the appropriateness of the level of care for morbidly obese subjects: validation of the CASCO-R scale

AIM

Aim of this study was to validate the Comprehensive Appropriateness Scale for the Care of Obesity in Rehabilitation (CASCO-R) and to determine the cut-off score for indicating the most appropriate health care setting for patients with obesity.

METHODS

The CASCO-R scale was developed according to the available scientific literature and expertise of an expert panel working for a Consensus document endorsed by the Italian Society of Obesity (SIO) and the Italian Society for the Study of Eating Disorders (SISDCA). 16 Italian centres, specialized in the treatment of obesity, characterised by different settings of care (specialist outpatient service, day-hospital service, intensive inpatient rehabilitation), participated in the study.

RESULTS

449 obese subjects were enrolled in the study (30.5% males and 69.5% females): 38.3% from outpatient services, 20.7% from day-hospital services and 40.9% from intensive inpatient rehabilitation units. After 2-month of treatment, a workload summary sheet, including medical and nursing interventions, number of expert advices and diagnostic procedures, and adverse clinical events (ACEs) was fulfilled for each patient. Statistically significant correlation was found between the CASCO-R scale score, overall workload and ACEs. The CASCO-R scale demonstrated also an excellent performance in terms of internal validity and test-retest analysis. Three total score cut-off have been proposed: >25 for inpatient intensive rehabilitation; 20-25 for day-hospital service; <20 for outpatient treatment.

CONCLUSIONS

In conclusion, the CASCO-R scale was demonstrated to be a valid tool for assessing the appropriateness of the choice of the level of care. Hence, it can be used to verify the proper allocation of patients, as it was well correlated with measures of workload and the incidence of ACEs.

Agreement between different versions of MNA

Malnutrition occurs frequently in the elderly with important clinical and functional consequences. Moreover, the treatment of malnutrition in the elderly may be effective if clinical and nutritional interventions are performed in the early stages. Therefore the early identification of the risk of malnutrition using validated and handy tools plays a pivotal role in terms of clinical outcome. Mini Nutritional Assessment (MNA) was validated for this purpose since many years but it is still ongoing the debate over whether the use of different items in certain clinical conditions can be effective without affecting the validity of the nutritional status evaluation. The aim of this study was to assess the agreement between different versions of MNA in the evaluation of nutritional risk in elderly subjects.

METHODS

522 subjects, 345 women and 177 men, were recruited from nursing homes or were free living in three different regions in Italy. All subjects underwent a multidimensional geriatric evaluation, addressed especially to nutritional status. We compared three different versions of MNA: the "original" version; a "proportional" MNA (MNA- P) in which the total MNA score was replaced by the ratio between the maximum score that each subject could obtain without including the body mass index (BMI) and the total original MNA score; and a third version in which calf circumference (CC) and mid- upper arm circumference (MAC) were used instead of BMI.

RESULTS

According to the original MNA, a high prevalence of malnutrition was found out in both genders (26% of women and 16.3% of men); both the versions of MNA, in which BMI was not considered, showed a good predictive value compared to original MNA. In particular, the MNA- P. showed an overall efficiency equal to 89,1% with specificity and positive predictive value respectively equal to 97.5% and 95.2%. MNA- CC- MAC showed even better results in terms of overall efficiency (91.4%), sensitivity (81.1%), specificity (97.1%), positive and negative predictive values (94.2% and 94.4%, respectively).

CONCLUSION

The different versions of MNA gave similar results in the classifications of subjects and in comparison with nutritional and biochemical parameters. Moreover MNA versions that did not considered BMI seem to be more effective in singling out subjects with risk factors related to malnutrition (disability, reduced strength and calf circumference, anaemia).

Taste loss in hospitalized multimorbid elderly subjects

BACKGROUND

Loss of the sense of taste is common among older people. Morbidities and polypharmacy may contribute to the age-related decline in gustatory function. The aims of the present study were to investigate taste perception in elderly hospitalized patients by comparing their taste recognition thresholds with those of healthy, free-living elderly individuals and to identify potential determinants of taste loss.

METHODS

The participants in this observational study were 55 elderly patients hospitalized in the acute geriatric section of the Department of Medical and Surgical Sciences at Padova University and 41 free-living individuals aged older than 65 years, randomly recruited from elderly people attending mild fitness programs at public gymnasiums in Padova. Data were collected on nutrition, health, cognitive, and functional status for all participants. Gustatory capabilities were assessed using aqueous solutions of sucrose, sodium chloride, citric acid, and quinine hydrochloride (representing sweet, salty, sour, and bitter stimuli, respectively), and taste recognition thresholds were measured in both groups.

RESULTS

In comparison with the free-living elderly subjects, those in hospital were significantly less able to recognize the taste of citric acid (P < 0.05). Low citric acid sensitivity was independently associated with advanced age (≥75 years; odds ratio [OR] 3.01, 95% confidence interval [CI] 1.01-9.82), polypharmacy (number of prescribed drugs ≥ 4; OR 2.74, 95% CI 1.01-7.72), and poor nutritional status (as assessed by Mini Nutritional Assessment score < 23.5; OR 5.08, 95% CI 1.76-14.6).

CONCLUSION

Because gustatory impairment may reduce a person's appetite and lead to inadequate dietary intake, compensatory nutritional measures, such as the use of flavor-enhanced foods, should be strongly encouraged, particularly in the hospital setting.

Measuring changes after multidisciplinary rehabilitation of obese individuals

BACKGROUND

In 2009, the Italian Society of Obesity developed the short-form questionnaire for Obesity-related Disabilities (TSD-OC).

AIMS

To stage the degree of disability in obese patients using TSD-OC; to verify its sensitivity to change after rehabilitation.

SUBJECTS

Three hundred and fifty-five adult obese individuals [body mass index (BMI) >30 kg/m2] undergoing rehabilitation. Exclusion criteria were severe cardiovascular or respiratory diseases, neurological and psychological conditions. Sensitivity to change of TSD-OC was evaluated in 194 patients out of the initial sample.

METHODS

To define the disability levels according to TSD-OC, the method of interquartile range was applied to the initial sample. The 194 in-patients were assessed with Roland-Morris Disability Questionnaire, Functional Independence Measure (FIM), Functional Visual Analogue Scale, and TSD-OC before (S0) and after 4 weeks (S1) of intensive (3 h daily) rehabilitation multidisciplinary program. Individuals were grouped according to age (1: age 30-59 yr; 2: age over 60 yr) and degree of obesity (BMI: A, 30-40 kg/m2; B, 40-50 kg/m2).

RESULTS

At S1, BMI and all the clinical scores improved significantly in the whole study sample. The younger individuals with higher level of obesity showed a higher functional improvement (-51.3%). In the older subjects, improvement was not statistically different when varying BMI (A2 -13.7% vs B2 -14.6%). In the whole group, the TSD-OC improvement was statistically greater than the physical FIM gain (-25.9% vs +5.4%, p<0.05).

CONCLUSIONS

Our data evidenced that the TSD-OC is a sensitive measure of short-term changes in disability status of obese individuals after rehabilitation.

Malnutrition in elderly: social and economic determinants

Malnutrition occurs frequently in the frailest groups of the population, especially in people who are on a low income and elderly subjects, overall if they are institutionalized. The aim of this study was to assess the prevalence of malnutrition in a sample of elderly people living in different settings and to identify the determinants of malnutrition.

METHODS

A total of 718 subjects, 472 females (F) and 246 males (M), were recruited from nursing homes or were free living in three different regions in Italy. Nutritional status, depression, social, functional and cognitive status, were evaluated.

RESULTS

According to the Mini Nutritional Assessment (MNA), a high prevalence of malnutrition was found out in both genders: 26% of F and 16.3% of M were classified as being malnourished (MNA<17); 40.9% of F and 35% of M were at risk of malnutrition (MNA 17-23,5). The prevalence of malnutrition was significantly higher in NH subjects in both sexes. Moreover, a relationship was shown between malnutrition and inability to shop, prepare and cook meals because of a low income, distance from markets or supermarkets as well as impossibility to drive the car or to use public transportation. This study confirms the necessity to routinely perform nutritional status evaluation in elderly subjects, to carry out training courses for health workers (doctors, nurses, psychologists, dietitians), to implement nutritional education of the geriatric population, to develop tools and guidelines for health workers and caregivers, to identify and reduce clinical, functional, social or economic risk factors for malnutrition.

Computer tailored nutrition education: Mediterranean diet

Goal of this work is to promote via on-line applications the knowledge of the Italian Weekly Pyramid, which is based on the concept of WI (Well Being Index) as a unit for a correct lifestyle. On the website www.piramideitaliana.it the user can verify his/her weekly lifestyle by participating in a "game" based on the introduction, for seven consecutive days, of food and beverages consumption and time assigned to physical activity. At the end of the seven days it is possible to access the page with an evaluation of dietary habits together with the possible suggestions for a correct lifestyle. On the basis of the data collected through this web game, a statistical analysis has been developed to evaluate the food habits and the level of physical activity. In the period between September 2005-January 2010 16,546 participants have completed the game. The data collected compare actual WI consumption for each food group with the one suggested by the Pyramid. The sample eating pattern appears almost varied; all the food groups were consumed daily, albeit in much lower quantities with regard to the suggested portions. It is pointed out that some differences in the nutritional habits are related to differences in age groups and in the school degree of the sample analyzed. This work highlights the importance of web-based tailored interventions on population food habits: many people can be reached to promote the knowledge of the guidelines leading to a healthy lifestyle.

A systematic review of the literature concerning the relationship between obesity and mortality in the elderly

INTRODUCTION

Obesity is a risk factor for chronic diseases and premature mortality, but the extent of these associations among the elderly is under debate. The aim of this systematic literature review (SR) is to collate and critically assess the available information of the impact of obesity on mortality in the elderly.

METHODS

In PubMed, there are three-hundred twelve papers on the relationship between obesity and mortality among older adults. These papers were analysed on the basis of their abstracts, and sixteen studies were considered suitable for the purpose of the study. It was possible to perform a pooled estimate for aggregated data in three different studies.

CONCLUSION

The results of this SR document that an increased mortality in obese older adults. The limitation of BMI to index obesity and the noted protective action of a moderate increase in BMI on mortality are highlighted. Waist circumference is an indicator of central adiposity and potentially as good a risk factor for mortality as BMI in obese elderly adults.

A pilot study to evaluate the effects of vardenafil on sexual distress in men with obesity

There are no interventional studies on the impact of sexual distress (SD) in men with obesity. We investigated the effects of vardenafil (VAR) on SD in middle-aged (mean age 49 ± 8), healthy, obese men in the absence of premature ejaculation, ED or hypogonadism. After a 4-week run-in period, 20 men with high body mass index (BMI=40 ± 8) and SD at the Sexual Distress Esteem Questionnaire-Male (mean score 65 ± 20 AU) were randomized to receive either VAR 10 mg on demand (N=10) or matched-placebo (PLB, N=10). Primary endpoints were variations from baseline in the intravaginal ejaculatory latency time (IELT) measured by the stopwatch technique; secondary endpoints were variations from baseline in Self-Esteem and Relationship (SEAR) and Male Sexual Health Questionnaire-Ejaculatory domain (MSHQ-EjD) scores. VAR significantly improved IELT (P<0.0001), as well as SEAR (P<0.001) and MSHQ-EjD (P<0.005) scores, whereas no changes were observed after PLB. Interestingly, an inverse relationship between BMI and IELT was found in all the men studied (r(2)=0.37, P<0.001). SD in healthy obese men seems to be correlated mainly with inadequate ejaculatory control, especially in men with higher BMI. Our preliminary results suggest that treatment with VAR may improve ejaculatory control, thus ameliorating self-esteem and sexual performance in men with obesity.

Senile anorexia in different geriatric settings in Italy

OBJECTIVES

Anorexia is the most frequent modification of eating habits in old age, which may lead to malnutrition and consequent morbidity and mortality in older adults. We aimed to estimate the prevalence and factors associated to anorexia in a sample of Italian older persons living in different settings. Our secondary aim was to evaluate the impact of senile anorexia on nutritional status and on eating habits, as well as on functional status.

DESIGN AND SETTING

Observational study in nursing homes, in rehabilitation and acute geriatric wards, and in the community in four Italian regions (Lazio, Sicily, Emilia-Romagna, and Veneto).

PARTICIPANTS

526 over 65 years old participants were recruited; 218 free-living subjects, 213 from nursing homes, and 96 patients from rehabilitation and acute geriatric wards in the context of a National Research Project (PRIN) from the Italian Ministry of Instruction, University and Research (2005-067913 "Cause e Prevalenza dell'Anoressia senile").

MEASUREMENTS

Anthropometric and nutritional evaluation, olfactory, chewing, and swallowing capacity, food preferences, cognitive function, functional status, depression, quality of life, social aspects, prescribed drugs, and evaluation of gastrointestinal symptoms and pain. Laboratory parameters included prealbumin, albumin, transferrin, C-reactive protein, mucoprotein, lymphocyte count, as well as neurotransmitters leptin, and ghrelin. Anorexia was considered as ≥50% reduction in food intake vs. a standard meal (using 3-day "Club Francophone de Gériatrie et Nutrition" form), in absence of oral disorders preventing mastication.

RESULTS

The overall prevalence of anorexia was 21.2% with higher values among hospitalized patients (34.1% women and 27.2% men in long-term facilities; 33.3% women and 26.7% men in rehabilitation and geriatric wards; 3.3% women and 11.3% men living in the community) and in the oldest persons. Anorexic subjects were significantly less self-sufficient and presented more often a compromised nutritional and cognitive status. Diet composition analyses of anorexic older adults revealed a lower intake of all food groups and a general tendency to a monotonous diet.

CONCLUSION

Anorexia is a frequent condition in older Italians, particularly those hospitalized, with important consequences in the nutritional and functional status. The analysis of dietary components and its quality along with the frequency of intake of single food groups may be useful to plan intervention strategies aiming to improve the nutritional and health status of older adults with anorexia. An early detection of anorexia followed by an adequate intervention in older hospitalized patients to avoid further worsening of clinical and functional status is warranted.

Predicting the outcome of long-term care by clinical and functional indices: the role of nutritional status

In elderly subjects, past researches have already underlined the role of nutritional status as a basic factor able to influence the prognosis either in acute wards or in rehabilitation and long-term care settings. Aim of the study is that of retrospectively verify, through a multivariate analysis, the factors able to condition mortality in long-term care, paying particular attention to the nutritional status.

METHODS

The survey included 513 patients aged more than 65 years admitted to a long-term care unit during a three years period. Exitus within the first three months of hospitalization was considered the outcome variable, while baseline functional, cognitive, clinical and nutritional status were considered the independent variables eventually related to mortality.

RESULTS

The univariate analysis found that some variables were significantly correlated with the outcome: comorbidity, ADL, cognitive status, pressure sores, albumin, transferrin, CRP, mucoprotein, cholesterol, cholinesterase, MAMC and MNA. The predictive value of the block model of the logistic regression analysis was 77.9% (specificity = 85.3%, sensitivity = 63.9%). With the forward stepwise analysis only MNA, cholinesterase, CRP and mucoprotein were considered in the final model. In this case the predictive value of the model was 79.3% (specificity = 84.6%, sensitivity = 69.46%).

[Impact of obesity-related disability in different work categories]

Absenteeism and sick leave are often reported in obese workers. To evaluate disability work related we assess 180 overweight-obese subjects [BMI 34,6 + 6,4, range 26,0-59,0) with TSD-OC questionnaire divided into 7 items (pain; stiffness; ADL; housework; IADL; occupational activities; social life) with a total of 36 visual analogue scales. Among the job categories, health-care workers showed the highest TSD-OC total score (26,9 + 22,5%, ANOVA p < 0,05) and BMI (BMI 37,7 + 6,9 kg/m2). Among the items, pain was statistically significant in health-care workers (16,1 + 13,2%), in Services (16,3 + 14,3%), in Education (15,1 + 11,4%) and in Administration (13,3 +11,0%) ( p <0,05). "Occupational activities" item was statistically significant in health-care (11, 6 +10,6%, p <0,05).

[Malnutrition in the elderly: clinical features, psychological and social determinants. Preliminary results]

In industrialized Countries malnutrition is a very frequent condition in frail groups of the population, people with low income and elderly subjects above all if institutionalized. The aim of the study is to: analyse the prevalence of malnutrition in a sample of elderly people located in different geographical areas in Italy; identify the psychological, social, economic, environmental, cultural and demographic determinants of malnutrition. The prevalence of malnutrition (estimated through the MNA) is high in both sexes (28% of F and 21.9% of M. Age, institutionalisation, health status, autonomy status, cognitive status and education level are some of the factors that correlate with the presence of malnutrition. Loneliness and poverty seem to have a negative impact on nutritional status but further data are needed to confirm this hypothesis. The data collected confirm the need to activate services dedicated to assess the nutritional status of elderly people, to implement campaigns in particular on food education for the elderly population, to set tools and guide lines for caregivers.

Obesity in the elderly

Obesity is a prevalent health disease among the elderly as it contributes to the early onset of chronic morbidity and functional impairment and is also related to premature mortality. The prevalence of sarcopenic-obesity increases too with age in each sex leading to a significantly higher prevalence of physical impairment and disability, as well as higher prevalence of metabolic syndrome. We observe a natural phenomenon (ageing) and a complex world-wide illness (obesity) that should not be merely treated as the sum of the treatments for the elderly and for the obese. The balance between the potential benefits of treatment interventions, reducing premature morbidity and mortality, and the impact on quality of life in old age may be different from young and adult age in case of obesity and need to be seriously considered.

Is obesity protective for osteoporosis? Evaluation of bone mineral density in individuals with high body mass index

BACKGROUND

Obese individuals often present comorbidities while they appear protected against the development of osteoporosis. However, few and contradictory data are now available on skeletal modifications in obese patients. The aim of this study was to characterise bone mineral density (BMD) in overweight (BMI > 25 < 29.9) and obese (BMI > 30) patients.

METHODS

We selected 398 patients (291 women, 107 men, age 44.1 + 14.2 years, BMI 35.8 + 5.9 kg/m(2)) who underwent clinical examination, blood tests and examination of body composition. Subjects with chronic conditions or taking medications interfering with bone metabolism, hormonal and nutritional status and recent weight loss were excluded.

RESULTS

Interestingly, 37% (n = 146) of this population showed a significantly lower than expected lumbar BMD: 33% (n = 98) of women showed a T-score -1.84 +/- 0.71, and 45% (n = 48) of men showed a T-score -1.88 +/- 0.64. When the population was divided into subgroups based on different BMI, it was noted that overweight (BMI > 25 < 29.9) was neutral or protective for BMD, whereas obesity (BMI > 30) was associated with a low bone mass, compatible with a diagnosis of osteoporosis. No differences were observed in hormones and lipid profiles among subgroups.

CONCLUSIONS

Our results indicate that a subpopulation of obese patients has a significant low lumbar BMD than expected for age. Thus, a careful characterisation of skeletal metabolism might be useful in all obese individuals to avoid fragility fractures later in life.

Nutrition, longevity and behavior

Nutrition offers the means to improve health and well-being and among the predictive factors of successful aging, nutrition appears as one of the major determinants. Whereas adequate nutrition plays a major role in a healthy lifestyle that maintains bodily and mental functioning, inadequate nutrition contributes to a loss of function and to the development and progression of disease. At the moment recommended dietary allowance (RDA) is established to cover the needs of populations of the healthy elderly. In the future special recommendations for subgroups of individuals are essential, taking into account individual health status and genetic factors. Nutrient guidelines for elderly are basically the same as for young adults, propagating a balanced varied nutrition that is rich in complex carbohydrate sources, fruits and vegetables providing fiber, antioxidant and functional nutrients, fish providing vitamin D and essential fatty acids, adequate water supply in view of their potentially impaired thirst perception and reduced renal functions. Finally a balanced diet is the best way to avoid deficiencies and maintain health. If in subgroups of the elderly population an adequate nutrition cannot be achieved, low dose dietary supplements and/or fortified foods and beverages can contribute to improve nutrient intake.

Nutrition in the elderly: role of fiber

Dietary fiber can be considered "any dietary component that reaches the colon without being absorbed in a healthy human gut". Thus "fiber", according to the recent literature, is contemplated any substance other than plant cell-wall material. The latter is a new definition expanding the previous one beyond carbohydrates. In fact, there is evidence that compounds other than cell-wall polysaccharides that are able to evoke similar physiological effects of those stimulated by soluble and insoluble polysaccharides. Moreover, this definition does not presume that the physiological effects of any fiber component are manifested only when fiber reaches the colon. Dietary fiber intake is important from a metabolic view point (lipid and glucose metabolism) or acting as prebiotics on microbiota health, in preventing colonic cancer, in treating bowel diseases and symptoms, on mineral absorption. Fiber intake seems to be important in particular in the elderly to the point that all national dietary guidelines and food guide pyramid for elderly people underline the necessity to increase dietary fiber intake, and therefore fruits and vegetables.

Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people an International Academy on Nutrition and Aging (IANA) Task Force

INTRODUCTION

The use of a simple, safe, and easy to perform assessment tool, like gait speed, to evaluate vulnerability to adverse outcomes in community-dwelling older people is appealing, but its predictive capacity is still questioned. The present manuscript summarises the conclusions of an expert panel in the domain of physical performance measures and frailty in older people, who reviewed and discussed the existing literature in a 2-day meeting held in Toulouse, France on March 12-13, 2009. The aim of the IANA Task Force was to state if, in the light of actual scientific evidence, gait speed assessed at usual pace had the capacity to identify community-dwelling older people at risk of adverse outcomes, and if gait speed could be used as a single-item tool instead of more comprehensive but more time-consuming assessment instruments.

METHODS

A systematic review of literature was performed prior to the meeting (Medline search and additional pearling of reference lists and key-articles supplied by Task Force members). Manuscripts were retained for the present revision only when a high level of evidence was present following 4 pre-selected criteria: a) gait speed, at usual pace, had to be specifically assessed as a single-item tool, b) gait speed should be measured over a short distance, c) at baseline, participants had to be autonomous, community-dwelling older people, and d) the evaluation of onset of adverse outcomes (i.e. disability, cognitive impairment, institutionalisation, falls, and/or mortality) had to be assessed longitudinally over time. Based on the prior criteria, a final selection of 27 articles was used for the present manuscript.

RESULTS

Gait speed at usual pace was found to be a consistent risk factor for disability, cognitive impairment, institutionalisation, falls, and/or mortality. In predicting these adverse outcomes over time, gait speed was at least as sensible as composite tools.

CONCLUSIONS

Although more specific surveys needs to be performed, there is sufficient evidence to state that gait speed identifies autonomous community-dwelling older people at risk of adverse outcomes and can be used as a single-item assessment tool. The assessment at usual pace over 4 meters was the most often used method in literature and might represent a quick, safe, inexpensive and highly reliable instrument to be implemented.

[A survey on diet manuals in Italian hospitals]

Hospital catering is very important to counteract the onset of malnutrition due to either undernutrition or overnutrition and for dietetic treatment. The aim of the study was to evaluate nutritional quality of the hospital dietetic manual used in some Italian hospitals and to analyze the role of the institutional Catering Service and of the Department of Clinical Nutrition. A survey has been carried out, in some Italian hospitals, using a questionnaire to point out the characteristics of hospitals, the typology of catering service, of the diets and of the staff of the Department of Clinical Nutrition. Only 22% of the hospitals has answered; three Italian regions (Umbria, Molise, Basilicata) are completely missing; -each hospital has a specific dietetic manual in most cases completely different from structure and nutritional quality point of view; the staff acting in this field is absolutely insufficient in term of numerousness and of professional typologies. Hospital in-patients are not homogeneous as for age, dietary needs and diseases, so it's necessary to treat them with an ad hoc nutritional intervention not established in advance in a dietetic manual; if from an organisation point of view it is necessary to have such a dietetic manual, it has to be based on nutritional guidelines and recommended dietary allowances.

[Mediterranean diet and prevention of non-communicable diseases: scientific evidences]

Epidemiological studies showed that the Mediterranean Diet represents a healthy food model in the maintenance of the state of health and in the improvement of the quality of life. The aim of this study was to define the relation between the Mediterranean Diet and the state of health, particularly the role in the prevention of the non-communicable diseases. A systematic literature review was made, analyzing clinical trials published on PubMed from January 2005 to September 2008 and using, separately or in combination, the key words: "Mediterranean Diet", "Health", "Prevention", "Diabetes", "Lipoproteins", "Cardiovascular Diseases", "Cancer." A total of 16 articles were selected. The studies included 101 to 25623 caucasian participants, of both genders, age between 18 and 80 years. Results were analyzed for the effects of the Mediterranean Diet on Cancer; Metabolic Syndrome and Cardiovascular Diseases, in terms of primary and secondary prevention. The Mediterranean Diet showed benefits on the incidence of cancer in healthy subjects, on the metabolic syndrome both in primary prevention that secondary, modifying numerous variables and about cardiovascular diseases, the Mediterranean Diet reduced the risk of relapse and the mortality by acute coronary syndromes and other cardiovascular causes in high risk patients. First of all the Mediterranean Diet must strongly be considered a correlated food model to the style of life, therefore it need further experimental research to validate the effects of Mediterranean Diet on the state of health.

Multidisciplinary approach to obesity

Obesity, associated with morbidity and mortality, is a complex disorder, characterised by an increase in fat mass (FM). Most authors agree in considering essential an integrated treatment made up of nutritional intervention, physical reconditioning programme and cognitive-behavioural psychotherapy. However, the feasibility is problematic and data in literature confirming the validity of this approach are poor.

AIM

To verify the efficacy of a multidimensional approach (Nutritional Psycho-Physical Reconditioning - NPPR) in obesity treatment.

METHODS

All patients admitted from June 2002 to June 2004 (464 subjects) ranged from 18 to 65 years old, with a body mass index (BMI) >30 kg/m2 were included in the programme. After the nutritional status evaluation a standard dietetic treatment (group N) or an integrated and multidisciplinary obesity treatment (group NPPR) was proposed.

RESULTS

In group NPPR treatment duration was significantly higher (142.6+/-26 vs 48.6+/-55 days - p=0.000), while the drop-out amount was definitely lower (5.5 vs 54.4%; p=0.000). Weight loss compared to the initial weight and the difference between initial and final FM resulted significantly higher in group NNPR. Subjects in NPPR obtained a higher increase in the distance covered in a 6-minute walk test (59.9+/-19 vs 40.5+/-17 m; p=0.04) and in muscular strength. State and trait anxiety, mood and quality of life scores improved in NPPR subjects while remained substantially stable in group N.

CONCLUSIONS

An integrated approach to obesity is the way to be pursued in order to obtain important and at least short-term results.

Senile anorexia in acute-ward and rehabilitations settings

The most common pathological change in eating behaviour among older persons is anorexia, which accounts for a large percent of undernutrition in older adults. The main research aims are to determine, in a sample of acute and rehabilitation elderly subjects, the prevalence of anorexia of aging and the causes most impacting on senile anorexia.

METHODS

four different Units cooperated to this research study. Patients were recruited from geriatric acute and rehabilitation wards in Italy. Each Research Unit, for the estimation of the prevalence of anorexia in elderly subjects evaluated all the patients aged over 65 recruited from April 2006 to June 2007. Nutritional status, depression, social, functional and cognitive status, quality of life, health status, chewing, swallowing, sensorial functions were evaluated in anorexic patients and in a sample of "normal eating" elderly subjects.

RESULTS

96 anorexic subjects were selected in acute and rehabilitation wards (66 women; 81.5 +/- 7 years; 30 men: 81.8 +/- 8 years. The prevalence of anorexia in the sample was 33.3% in women and 26.7% in men. Anorexic subjects were older and more frequently needed help for shopping and cooking. A higher (although not statistically significant) level of comorbidity was present in anorexic subjects. These subjects reported constipation and epigastrium pain more frequently. Nutritional status parameters (MNA, anthropometry, blood parameters) were significantly worst in anorexic subjects whereas CRP was higher. Chewing and swallowing efficiencies were significantly impaired and eating patterns were different for anorexic subjects with a significant reduction of protein rich foods.

CONCLUSIONS

consequences of anorexia can be extremely serious and deeply affect both patient's mobility, mortality and quality of life. Therefore, it is of utmost importance to perform a special evaluation of the nutritional risk, to constantly evaluate the nutritional status and feeding intake of older patients, to identify and treat the underlying disease when possible, to institute environmental and behavioural modifications, to organise staff better in order to produce higher quality feeding assistance during mealtimes, to plan early nutrition rehabilitation and nutritional education programs for caregivers. There is also the necessity to develop diagnostic procedures easy to perform, able to identify the pathogenesis of anorexia and, therefore, treatment strategies exactly fitting the patients' needs.

Systematic review of nutritional status evaluation and screening tools in the elderly

One univocal definition for nutritional status (NS) does not exist. One set of generally accepted standards for assessing the nutritional status does not exist, either. The NS assessment is absolutely necessary because it drives to identify malnutrition which is a potential cause and or an aggravation of morbidity and mortality. Since malnutrition shows a high prevalence in the elderly, literature about the validation of tools exploring single or complex NS parameters in the elderly has been systematically review. 115 papers, published from January 1st 1990 to July 31st 2003, have been identified: among them, just 9 complied with the established quality criteria and were suitable to be systematically reviewed. Parameters and diagnosis protocols to assess NS used in the selected papers were not homogeneous. Two implications arise from this evidence: - as regards clinical practice: an assessment on NS in clinical practice is complex, but not impossible. Hopefully, despite the absence of a sure reference, nutritionists, during their own clinical practice, ought to choose a validated on their own population and complete tool (considering as NS indicators both dietetic, anthropometric and functional parameters) for NS assessment, among all the redundant set of tools proposed until now; - respecting a scientific point of view, there is the necessity for calling a consensus conference in order to establish an initial consensus to diagnose malnutrition in the elderly and to promote, therefore, a validation study.

Nutritional status determinants and cognition in the elderly

It is possible to identify risks or protective factors against dementia. Increased levels of homocysteine (HCY) and vitamin B deficiency, obesity and central adiposity in midlife are independent risk factors for the development of dementia. High dietary intake of antioxidants and omega-3 fatty acids lower the risk of Alzheimer disease (AD). The supplementation with single nutrients, like vitamin B, omega-3-polyunsaturated fatty acids (PUFA) or antioxidants is generally not effective in lowering the risk of dementia or in slowing the progression of the disease. It is probably necessary that these nutrients are part of a healthy diet (with at least five portions of fruit and vegetables per day and one portion of fish per week) during the lite where other factors interact with them as it happens in the Mediterranean diet. Nutritional strategies for modifying the clinical course of cognitive failure should consider the use of nutritional screening tools in the multidimensional geriatric evaluation. Moreover, the diet, oral supplementation, caregiver education could be important factors to prevent or treat weight loss and its consequences in AD while the use of artificial nutrition in demented patients may have questionable benefits.

Nutritional status and evolution of pressure sores in geriatric patients

The prevalence of pressure sores (PS) ranges from 1 to 18% of in-patients and from 3 to 28% of those admitted to long-term settings. The aim of our study was to verify, a posteriori, how nutritional status influenced the evolution of PS in a population of elderly subjects hospitalised in a long-term care setting.

MATERIALS AND METHODS

The charts of 125 patients with ulcerative or necrotic pressure ulcers were evaluated retrospectively. For each subject we took note of: PS characteristics (stage, ulcer surface, evolution), clinical characteristics (comorbidity, adverse clinical events, cognitive, functional and nutritional status).

RESULTS

In 58 patients (46.4%) there was overall healing of the lesions while in 39 patients (31.2%) we had however an "improvement" of PS. The course of PS was not significantly influenced by the patient's physiological characteristics, by cognitive status or by initial characteristics of PS. Instead, we noticed a significant difference in the course of PS as a function of the level of autonomy and clinical status. The course of PS, and in particular the Healing Index, were influenced by the Nutritional Status and, above all, by its course during the treatment period.

CONCLUSIONS

The development of PS is multifactorial. Whereas, it is clear that factors other than nutrition influence the risk of developing PS, an important role for nutrition in the development and resolution of PS is suggested. Our data certainly confirm the "Quality indicators for prevention and management of pressure ulcers in vulnerable elders", especially were they say "if a vulnerable elder is identified as at risk for pressure ulcer development and has malnutrition, then nutritional intervention or dietary consultation should be instituted because poor diet, particularly low dietary protein intake, is an independent predictor of pressure ulcer development".

Orthorexia nervosa: validation of a diagnosis questionnaire

AIM

To validate a questionnaire for the diagnosis of orhorexia oervosa, an eating disorder defined as "maniacal obsession for healthy food".

MATERIALS AND METHODS

525 subjects were enrolled. Then they were randomized into two samples (sample of 404 subjects for the construction of the test for the diagnosis of orthorexia ORTO-15; sample of 121 subjects for the validation of the test). The ORTO-15 questionnaire, validated for the diagnosis of orthorexia, is made-up of 15 multiple-choice items.

RESULTS AND CONCLUSION

The test we proposed for the diagnosis of orthorexia (ORTO 15) showed a good predictive capability at a threshold value of 40 (efficacy 73.8%, sensitivity 55.6% and specificity 75.8%) also on verification with a control sample. However, it has a limit in identifying the obsessive disorder. For this reason we maintain that further investigation is necessary and that new questions useful for the evaluation of the obsessive-compulsive behavior should be added to the ORTO-15 questionnaire.

Orthorexia nervosa: a preliminary study with a proposal for diagnosis and an attempt to measure the dimension of the phenomenon

AIM

To propose a diagnostic proceeding and to try to verify the prevalence of orthorexia nervosa (ON), an eating disorder defined as "a maniacal obsession for healthy foods".

MATERIALS AND METHODS

404 subjects were enrolled. Diagnosis of ON was based on both the presence of a disorder with obsessive-compulsive personality features and an exaggerated healthy eating behaviour pattern.

RESULTS

Of the 404 subjects examined, 28 were found to suffer from ON (prevalence of 6.9%). The analysis of the physiological characteristics, the social-cultural and the psychological behaviour that characterises subjects suffering from ON shows a higher prevalence in men and in those with a lower level of education. The orthorexic subjects attribute characteristics that show their specific "feelings" towards food ("dangerous" to describe a conserved product, "artificial" for industrially produced products, "healthy" for biological produce) and demonstrate a strong or uncontrollable desire to eat when feeling nervous, excited, happy or guilty.

MNA predictive value in the follow-up of geriatric patients

OBJECTIVE

The aim of this study is to verify, in a sample of elderly subjects admitted to long-term care, the impact of malnutrition, according to the Mini Nutritional Assessment (MNA), on mortality and on the occurrence of Adverse Clinical Events in a 3-12 months follow-up study.

SUBJECTS

The survey included all patients admitted to a geriatric hospital--"Villa delle Querce", Nemi (Rome, Italy)--between January 1997 and April 2000, whose nutritional status we were able to monitor for over 3 months. The study comprised 167 elderly subjects, of which 125 women (74.9%) aged 83.3 8 years (60-95 years), and 42 men (25.1%) aged 79.6 9 years with an average follow-up period of 7.5 months.

METHODS

Upon admission and at every check we evaluated each subject's cognitive functions, functional status, co-morbidity, frailty, nutritional status (anthropometric and biochemical indices; MNA). During the follow-up we recorded Adverse Clinical Events. We calculated the predictive value of MNA, we correlated variations in MNA scores with variations of nutritional parameters.

RESULTS

MNA's predictive ability both upon admission and upon discharge was found to be excellent. The MNA score was found to be correlated-although not to a very high degree-with variations nutritional parameters. Even more than malnutrition, a low MNA score was found to be predictive of a greater incidence of Adverse Clinical Events during hospitalisation and of higher mortality.

[The quality of a restaurant service at a geriatric rehabilitation facility]

The aim of our study was to measure the quality of a restaurant service of a geriatric rehabilitation and long-term setting as it is perceived from patients compared with an objective measure of the quality. We have also verified the weight of the restaurant service on the whole quality of the hospital. Our data showed some problems in the organisation of the service, a substantially negative judgment from patients, the necessity to integrate subjective judgments with objective evaluations. The data confirmed also the importance that patients give to taste and variability of food and to the way in which it is presented. The results we obtained suggested an audit of the organisation of the restaurant service. The outcome of the proposed changes will be followed up and bring, eventually, to further arrangements.

Administering the "AHSP Questionnaire" (appetite, hunger, sensory perception) in a geriatric rehabilitation care

BACKGROUND

Frail elderly people, living in nursing homes, usually show a malnutrition state caused by an increased need of energy or an inadequate food intake. Among the causes leading to reduction of food intake in elderly people and consequently to malnutrition, is the loss of appetite, often marker of depression and alterations of taste and smell perception.

OBJECTIVE

The aim of this research is to verify the application of the AHSP Questionnaire and relate its score to nutritional state of a frail elderly population hospitalized in a geriatric rehabilitation care.

SETTING AND SUBJECTS

All patients of the "3rd Rehabilitation Department" of the Istituto Geriatrico "Villa delle Querce" Nemi (Rome-Italy).

METHODS

Informations, number and type of medical conditions, prescribed drugs, other parameters that can affect taste, smell, hunger and nutritional status, mood, cognitive and nutritional status have been collected from the clinical folders. To assess appetite, hunger smell and taste perception had been submitted the AHSP Questionnaire.

RESULTS

The AHSP Questionnaire had been administered only to 44 of the 103 patients present at the survey because of the high prevalence of cognitive impairment. AHSP score is lower in presence of malnutrition assessed with MNA (Mini Nutritional Assessment). MNA, expressed as proportional score, seems to present a clear correlation with AHSP's (r=0.59; p=0.000).

CONCLUSION

The results achieved show the scarce adaptability of the AHSP Questionnaire to frail elderly people living in geriatric rehabilitation care. MNA is at the moment the most reliable tool to single out dietary deficiency on geriatrics population.

A "proportional and objective score" for the mini nutritional assessment in long-term geriatric care

BACKGROUND

In a previous study we tested the predictive value of the Mini Nutritional Assessment (MNA) in an Italian population of frail elderly in long-term hospital care. The results of our study confirmed the MNA's excellent overall predictive value and sensitivity. Unfortunately we had a large number of false positive judgments, hence our study's low specificity, which we think was caused by two factors: 1. in most cases it was impossible to conduct a reliable subjective assessment of the patients' nutritional and health status. 2. most patients failed to respond to some of the MNA questions, which as a consequence received a "0" score. The result was an artificially low global MNA score even in well-nourished patients.

OBJECTIVE AND DESIGN

We tried to neutralize the effects of the defective answers by modifying the total score and the cut-off points of the test. Thus, we: 1. replaced the subjective assessment of health and nutritional status with an objective evaluation; 2. replaced the total score of MNA with the ratio of this value with the maximum of points that each subject can obtain without including the items for which we could not have a response. Similarly, the cut-off points (17 and 24) were replaced with the ratio of these values with the maximum of points obtainable by a complete MNA (30). Patients are classified as "malnourished" below 0.56, "at risk of malnutrition" between 0.56 and 0.79, and "well-nourished" from 0.8 up.

RESULTS

This way, the overall predictive value of MNA is increased from 80.3 to 85.4% and the specificity from 12.8 to 25%, whereas the sensitivity increase is modest (from 98 to 98.1%).

Prediction of stature in the Italian elderly

Adequate quantification of weight and stature is essential in order to determine levels of nutritional support and to monitor the effects of nutritional intervention. Traditional anthropometric techniques are difficult to apply in elderly or handicapped patients chair or bed-bound. The purpose of the present study is to elaborate regression equations for the estimation of stature in the italian elderly population from other anthropometric measures that can be more easily determined. We have found a single model valid for both sexes (in which the value of the variable "sex" equals 0 if woman and 1 if man) to predict stature in italian elderly: Stature = 94.87 + 1.58 knee-height - 0.23 age + 4.8 sex. Cross validation on a control sample of 30 males and 54 females yielded pure errors of 3.1 cm for men and 2.74 cm for women.