Clinical Nutrition

Editorial Board

2009-12-01

Dangers, and benefits of the cytokine mediated response to injury and infection

Peter B. Soeters, Robert F. Grimble — 2009-07-15

Summary: The inflammatory response is essential for survival in an environment where continuous exposure to noxious events threaten the integrity of the organism. However, the beneficial effects of the response are influenced by factors, which disadvantage individuals within a population. These factors include malnutrition, infection, genotype, gender, pre-existing inflammation, and chronic intoxication. Although the inflammatory response is generally successful in dealing with noxious events, life-long exposure to these events takes its toll on the integrity of the body and becomes apparent as chronic disease, atherosclerosis, organ failure, and frailty.Progress in ameliorating the consequences of lifetime exposure to inflammatory events can only occur if a fuller understanding can be obtained of the factors, which influence the persistence and outcome of the inflammatory response at an individual level. A multitude of studies has shown that specific nutrients, diets, and dietary restriction are able to modulate the inflammatory response in the population as a whole. To advance in this area, precise knowledge is needed of how the disadvantageous factors, mentioned above, affect the individual's response to anti-inflammatory nutrients.

Growth hormone and protein metabolism

2009-09-07

Summary: Growth hormone (GH) and intracellular STAT 5 signalling represents a very old regulatory system and, whereas insulin dominates periprandially, GH may be viewed as the primary anabolic hormone during stress and fasting. GH exerts metabolic effects both directly and through stimulation of IGF-I, insulin, and free fatty acids (FFA). When well nourished the GH-induced stimulation of IGF-I and insulin is important for tissue anabolism whereas during fasting and other catabolic states GH predominantly stimulates the release and oxidation of FFA which leads to decreased glucose and protein oxidation and preservation of LBM. The most prominent metabolic effect of GH is a marked increase in lipolysis and FFA levels. In the periprandial and postabsorptive states the effects of GH on protein metabolism are modest and include increased protein synthesis and decreased breakdown at the whole body level and in muscle together with decreased amino acid degradation/oxidation and decreased hepatic urea formation. During fasting and stress the effects of GH on protein metabolism become more pronounced; lack of GH during fasting increases protein loss and urea production rates by ≈ 50% with a similar increase in muscle protein breakdown. The importance of GH is further substantiated by the observations that adult patients with GH-deficiency are obese and have reduced LBM, and impaired physical performance and acromegaly is characterised by increased LBM and decreased fat mass.

Nutritional and exercise-based interventions in the treatment of amyotrophic lateral sclerosis

Barkha P. Patel, Mazen J. Hamadeh — 2009-09-27

Summary: Background & aims: Disease pathogenesis in amyotrophic lateral sclerosis (ALS) involves a number of interconnected mechanisms all resulting in the rapid deterioration of motor neurons. The main mechanisms include enhanced free radical production, protein misfolding, aberrant protein aggregation, excitotoxicity, mitochondrial dysfunction, neuroinflammation and apoptosis. The aim of this review is to assess the efficacy of using nutrition- and exercise-related interventions to improve disease outcomes in ALS.Methods: Studies involving nutrition or exercise in human and animal models of ALS were reviewed.Results: Treatments conducted in animal models of ALS have not consistently translated into beneficial results in clinical trials due to poor design, lack of power and short study duration, as well as differences in the genetic backgrounds, treatment dosages and disease pathology between animals and humans. However, vitamin E, folic acid, alpha lipoic acid, lyophilized red wine, coenzyme Q10, epigallocatechin gallate, Ginkgo biloba, melatonin, Cu chelators, and regular low and moderate intensity exercise, as well as treatments with catalase and l-carnitine, hold promise to mitigating the effects of ALS, whereas caloric restriction, malnutrition and high-intensity exercise are contraindicated in this disease model.Conclusions: Improved nutritional status is of utmost importance in mitigating the detrimental effects of ALS.

Fast-track in open intestinal surgery: Prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456)

2009-07-15

Summary: Background: Studies have shown the value of using fast-track postoperative recovery. Standard procedures (non-fast-track strategies) remain in common use for perioperative care. Few prospective reports exist on the outcome of fast-tracking in Central Europe. The aim of our study was to assess the effect and safety of our own fast-track protocol with regard to the postoperative period after open bowel resection.Patients and methods: One hundred and five patients with ASA score I–II scheduled for open intestinal resection in the period April 2005–December 2007 were randomly selected for the fast-track group (FT) and non-fast-track group (non-FT). A designed protocol was used in the FT group with the emphasis on an interdisciplinary approach. The control group (non-FT) was treated by standard established procedures. Postoperative pain, rehabilitation, gastrointestinal functions, postoperative complications, and post-op length of stay were recorded.Results: Of 105 patients, 103 were statistically analyzed. Patients in the FT group (n=51) and non-FT group (n=52) did not differ in age, surgical diagnosis, or procedure. The fast-track procedure led to significantly better control of postoperative pain and faster restoration of GI functions (bowel movement after 1.3 days vs. 3.1, p<0.001). Food tolerance was significantly better in the FT group and rehabilitation was also faster. Hospital stay was shorter in the FT group – median seven days (95% CI 7.0–7.7) versus ten days (95% CI 9.5–11.3) in non-FT (p<0.001). Postoperative complications within 30 postoperative days were also significantly lower in the FT group (21.6 vs. 48.1%, p=0.003). There were no deaths and no patients were readmitted within 30 days.Conclusions: Following the FT protocol helped to reduce frequency of postoperative complications and reduced hospital stay. We conclude that the FT strategy is safe and effective in improving postoperative outcomes.

Experiences of food access in hospital. A new questionnaire measure

2009-07-15

Summary: Background & aims: People in hospital experience problems gaining access to food. We aimed to develop an experience-based measure of access to food.Methods: The 27-item questionnaire has five domains: feeling hungry, physical barriers, organisational barriers, food choice and food quality. A survey was implemented on 29 wards in four hospitals using both self-completion and interview administration formats.Results: Questionnaires were analysed for 764/1154 (66%) eligible participants. Values for Cronbach's alpha were: feeling hungry 0.886; physical barriers 0.809; organisational barriers 0.632; food choice 0.414; and food quality 0.738. The proportions of compromised patients in each domain were: hunger 30%; physical barriers 24%; organisational barriers 29%; food choice 24%; and food quality 21%. Poor self-rated health was associated with increased problems from feeling hungry (adjusted odds ratio 2.39, 95% confidence interval 1.10–5.18); older age was associated with increased difficulties with physical problems (2.67, 1.31–5.42) as were admission to a stroke ward (16.8, 5.09–55.3) or elderly care ward (3.50, 1.08–11.40). Problems with food access varied between hospitals and wards.Conclusions: We have developed a reliable and valid questionnaire measure of hospital food access. The measure reveals widespread problems of food access in hospital.

Olive oil-based intravenous lipid emulsion in pediatric patients undergoing bone marrow transplantation: A short-term prospective controlled trial

2009-07-15

Summary: Background: & aims: Parenteral nutrition (PN) is an important component of the supportive care of children undergoing bone marrow transplantation (BMT). The study aimed to assess short-term safety and metabolic effects of an olive oil-based (OO) lipid emulsion compared with a MCT/LCT (M/L) emulsion in the clinical setting of pediatric BMT.Methods: Twenty-eight pediatric BMT patients (age 1–18years) expected to need PN support for at least 2weeks, were prospectively enrolled and randomly assigned to receive either OO or M/L lipid emulsions within PN. Clinical and routine laboratory parameters, plasma fatty acids profile, vitamin E and peroxidation status were recorded at baseline and after 14days of PN.Results: No significant differences were found for hematological parameters, liver enzymes, vitamins, plasma peroxidation status, percentage and time to engraftment. Taking into consideration the baseline fatty acids levels, the OO group showed higher oleic acid (p=0.012), linoleic (p=0.012) and arachidonic acid (p=0.002) enrichment but similar eicosapentanoic and docosahexanoic acids levels compared to the M/L group at day 14. Cholesterol levels decreased significantly in the OO group after 14days on PN (p=0.017).Conclusions: OO lipid emulsion was well tolerated, maintained essential fatty acids and peroxidation status, and generated a favorable plasma lipid profile. In this study short-term use of OO intravenous lipid emulsions was safe in children who needed PN support during BMT.

Gastric emptying of three liquid oral preoperative metabolic preconditioning regimens measured by magnetic resonance imaging in healthy adult volunteers: A randomised double-blind, crossover study

2009-07-15

Summary: Background & aims: Preoperative starvation has many undesirable effects but the minimum length of fasting is limited by gastric emptying, which may be dependent on nutrient content, viscosity and osmolarity of the feed. We compared the gastric emptying of two types of preoperative metabolic preconditioning drinks [Oral Nutritional Supplement (ONS) (Fresenius Kabi, Germany) and preOp® (Nutricia Clinical Care, UK)] in healthy volunteers.Methods: Twenty (10 male, 10 female) healthy adult volunteers were studied on 3 separate occasions in a randomised crossover manner. Volunteers ingested 400ml preOp®, which is a clear carbohydrate drink (CCD) (50g carbohydrate, 0g protein), 70g ONS (50g carbohydrate and 15g glutamine) dissolved in water to a total volume of 400ml (ONS400) and 300ml (ONS300). Gastric emptying time was measured using magnetic resonance imaging.Results: Mean (95% CI) T50 and T100 gastric emptying times for CCD were significantly lower (p<0.001) compared with ONS400 and ONS300. T50 was 47 (39–55), 78 (69–87) and 81 (70–92)min for CCD, ONS400 and ONS300 respectively. Correspondingly T100 was 94 (79–110), 156 (138–173) and 162 (140–184)min. Residual gastric volumes returned to baseline 120min after CCD and 180min after ONS400 and ONS300.Conclusions: The faster gastric emptying for CCD compared to ONS400 and ONS300 signifies that gastric emptying may be more dependent on nutrient load than volume or viscosity in healthy volunteers. While it is safe to give CCD 2h preoperatively, ONS400 and ONS300 should be given at least 3h preoperatively.

Highly elevated C-reactive protein levels in obese patients with COPD: A fat chance?

2009-07-15

Summary: Background & aims: Chronic obstructive pulmonary disease (COPD) has been recognized as a multi component disease. Currently, limited data are available about determining factors of systemic inflammation in COPD, in particular C-reactive protein (CRP).The aim was to determine whether and to what extent COPD patients with a low, high or obese body mass index (BMI) are more likely to have elevated CRP levels compared to normal-weight COPD patients. Furthermore, we aimed to explore the effects of clinically relevant covariates on the likelihood of having elevated CRP levels.Methods: In 628 elderly patients with moderate to severe COPD (61% male), lung function and BMI were assessed before entering pulmonary rehabilitation. In addition, blood was collected in the fasted state. High-sensitive C-reactive protein (CRP) was classified into: normal, ≤3; elevated, >3–5 and highly elevated, >5mg/l.Results: Obese COPD patients (BMI≥30kg/m2) were 3.3 times more likely (95% CI, 1.5–7.0, p=0.002) to have highly elevated CRP levels compared to normal weight (BMI 21—24.9kg/m2) COPD patients after taking clinically relevant confounders into account. In contrast, COPD patients with a low BMI (<21kg/m2) were 2 times less likely (OR, 0.5; 95% CI, 0.3–0.9, p=0.022) to have highly elevated CRP levels compared to normal-weight peers.Conclusion: Obese BMI is associated with highly elevated CRP levels in patients with COPD. These findings are suggestive for an adipocyte-induced systemic inflammation in COPD.

Half-solidification of nutrient does not decrease gastro-esophageal reflux events in patients fed via percutaneous endoscopic gastrostomy

2009-07-15

Summary: Background & aims: Percutaneous endoscopic gastrostomy (PEG) tube feeding is widely used for patients with swallowing dysfunction, and aspiration pneumonitis induced by reflux of gastric contents is one of the most frequent and life-threatening events in such patients. We performed this study to clarify the effect of half-solidification of nutrient on gastro-esophageal reflux (GER) of acidic and non-acidic gastric contents in patients with PEG.Methods: The subjects were 14 elderly patients undergoing PEG feeding (female: 11, mean age 83.1y). Twenty-four hour esophageal multichannel intraluminal impedance (MII) and pH (MII-pH) monitoring were performed during and after feeding with half-solid and liquid nutrient, respectively. The numbers of GER events during 4h after the start of feeding were compared.Results: There was no significant difference in the total number of GER events between half-solid nutrient feeding and liquid nutrient feeding (5.6±1.5 vs. 6.6±1.5). The number of acid reflux events after half-solid nutrient feeding tended to be higher than that after liquid nutrient feeding (1.9±1.1 vs. 1.4±0.8).Conclusion: Half-solidification of nutrition does not appear to be effective for preventing GER caused by liquid PEG feeding.

Impact of disease activity on resting energy expenditure in children with inflammatory bowel disease

2009-07-15

Summary: Background and aims: Exclusive enteral nutrition is used as primary therapy in Crohn's disease. Nutrition support is frequently required in children with both Crohn's disease and Ulcerative Colitis when acutely unwell and during periods of recovery. There is considerable controversy about nutritional needs during phases of active and inactive disease. It is, for example, often assumed that in acute illness a child requires increased nutritional support however the precise relationship between illness severity and energy expenditure is uncertain. This study explores the relationship between disease activity and resting energy expenditure (REE) in children with inflammatory bowel disease.Methods: Patients were recruited from the regional paediatric gastroenterology unit at Southampton University Hospitals NHS Trust. Disease activity was assessed using standard scoring systems (Paediatric Crohn's Disease Activity Index; Simple Colitis Activity Index) and biochemical markers of inflammation (C-Reactive Protein, CRP). Fat free mass was estimated from skinfold thickness and Bioelectrical Impedance Analysis. Resting energy expenditure was measured by indirect calorimetry. A logarithmic correction and a linear regression model were used for analysis of REE corrected for body size.Results: 55 children were studied; 37 (67%) with Crohn's disease and 18 (33%) with Ulcerative Colitis. Median PCDAI was 10 (range 0–60), 22 (59%) had PCDAI ≥10 (active disease). Median SCAI was 1.5 (range 0–12). Within disease groups there were strong correlations between REE/KgFFM0.52 and disease activity; PCDAI (r −0.386, p 0.018) in Crohn's disease and SCAI (r −0.456, p 0.057) in Ulcerative Colitis. In the cohort as a whole there was no increase in REE/KgFFM0.52 with increasing CRP (r 0.129, p 0.361). Using the regression model each mg/l increase in CRP was associated with a reduction in REE of nearly 1.5kCal/day.Conclusions: We were unable to demonstrate a significant relationship between REE and disease activity in children with inflammatory bowel disease.

Short chain fatty acids exchange across the gut and liver in humans measured at surgery

2009-07-15

Summary: Background & aims: Short chain fatty acids (SCFAs; acetate, propionate and butyrate) are important energy sources for colonocytes and are assumed to play a key role in gut health. Local effects of SCFAs have been investigated, but less is known about whole body metabolism of these SCFAs. The aim of the present study was to quantify the role of the gut and liver in interorgan exchange of SCFAs in humans in vivo.Methods: Twenty-two patients undergoing major upper abdominal surgery were studied. Blood was sampled from a radial artery, the portal and a hepatic vein. Portal, splanchnic and arterial blood flow was measured using intra-operative Duplex ultrasonography. SCFAs were measured on a liquid chromatography system combined with mass spectrometry.Results: SCFAs were released by the gut, 34.9 (9.1)μmolkg bodyweight−1h−1. SCFAs uptake by the liver was significant for propionate and butyrate; −5.6 (1.3) and −3.8 (1.6)μmolkg bodyweight−1h−1 (p=0.0002 and p=0.03) respectively and counterbalanced gut release. Liver uptake of acetate was not significant, −5.2 (6.6)μmolkg bodyweight−1h−1 (p=0.434). Splanchnic (i.e., gut+liver) SCFAs release was significant for acetate and propionate, 17.3 (7.3) and 1.2 (0.4)μmolkg bodyweight−1h−1 (p=0.027 and p=0.0038), respectively. Splanchnic release of butyrate was not significantly different from zero (1.9 (1.2)μmolkg bodyweight−1h−1, p=0.129). BMI and previous colonic resection did not affect gut release of SCFAs.Conclusion: This is the first in vivo study on the role of the gut and liver in SCFAs exchange in humans in vivo. It is shown that intestinal SCFAs release by the gut is equalled by hepatic uptake.

Tocopherol isomer pattern in serum and stool of human following consumption of black currant seed press residue administered in whole grain bread

Dorit Helbig, Andreas Wagner, Rainer Schubert, Gerhard Jahreis — 2009-07-15

Summary: Background & aims: Serum γ-tocopherol is thought to be associated with human health. The dietary influence of tocopherol and fibre-rich black currant seed press residue on serum and stool tocopherol concentration was investigated in a controlled human intervention study.Methods: Thirty-six women consumed bread enriched with black currant press residue (4 weeks). The resultant faecal and serum tocopherol concentrations were compared with those after a period consuming control bread without press residue and a normal baseline diet. Fibre intake and excretion, antioxidant capacity (TEAC), and vitamin C concentrations in serum and urine were also determined. Samples were obtained with a 5-day standardised diet at the end of each period.Results: The press residue bread lead to significantly increased β-, γ-, δ- and total tocopherol intake, serum α-, β-, γ- and total tocopherol concentration (with and without lipid adjustment), fibre intake and urinary vitamin C concentration compared to control bread (P<0.05). Faecal excretion of total tocopherols and fibre increased compared to baseline (P<0.05).Conclusions: Fibre intake and excretion influence total tocopherol concentration in lipid-adjusted serum and in stool. The outstandingly high increase of serum γ-tocopherol concentration through seed press residue consumption could be due to a presumed interruption of the enzymatic tocopherol degradation mechanism by bread constituents.

Enteral nutrition rapidly reverses total parenteral nutrition-induced impairment of hepatic immunity in a murine model

2009-07-15

Summary: Background & aims: Total parenteral nutrition (TPN) impairs host immunocompetence, a mechanism possibly underlying the high morbidity of infectious complications in critically ill patients. Our recent study demonstrated TPN to reduce the number and function of hepatic mononuclear cells (MNCs) and to worsen survival after intraportal Pseudomonas challenge in mice. The present study examined the duration of enteral nutrition (EN) needed to reverse TPN-induced changes in hepatic MNCs in a murine model.Methods: Male ICR mice (6 weeks) received 5 days of TPN followed by 0 (TPN), 12 (EN12), 24 (EN24), 48 (EN48) or 72 (EN72)h of chow feeding. Control mice (Control) were given chow with intravenous saline infusions for 5 days. After nutritional support, hepatic MNCs were isolated and counted. Lipopolysaccharide (LPS) receptor expressions (CD14 and TLR4/MD2) on Kupffer cells were analyzed by flowcytometry. In addition, TPN, EN12, EN48 and control mice were given intraportal Pseudomonas challenge and survival was monitored.Results: The TPN group was significantly lower in hepatic MNC number and LPS receptor expressions than the Control group. However, EN quickly reversed TPN-induced hepatic impairments in MNC loss within 12h, CD14 expression within 48h and TLR4/MD2 expression within 24h. Survival of the EN48 group was significantly improved as compared with the TPN and EN12 groups.Conclusions: EN rapidly reverses TPN-induced impairment of hepatic immunity along with increased hepatic MNC numbers and LPS receptor expressions on Kupffer cells.

Administration of Chlorella sp. microalgae reduces endotoxemia, intestinal oxidative stress and bacterial translocation in experimental biliary obstruction

2009-07-09

Summary: Rationale: Endotoxemia has long been documented in obstructive jaundice, and altered intestinal barrier function is considered to be one of the important mechanisms for this phenomenon. The aim of this study was to investigate the role of different microalgae (Chlorella sp. and Spirulina sp.) extracts in intestinal barrier function and oxidative stress in experimentally jaundiced rats.Methods: A total of 60 male wistar rats were randomly divided into four groups of 15 each: I, sham operated; II, bile duct ligation (BDL); III, BDL+Chlorella sp.; IV, BDL+Spirulina sp. Rats were fed rat chow or microalgae extracts supplemented enteral diet ten days after sham operation or BDL. Main outcome measures were endotoxin concentrations in plasma, evidence of bacterial translocation (BT) in mesenteric lymph nodes (MLNs) and liver, oxidative stress, and histology.Results: Compared to the group I, a significant increase in contamined MLNs, liver, and spleen samples and increased endotoxemia were noted in group II (P<0.01) but were significant reduced in group III (P<0.05). There was no significant difference in BT rate between the group II and group IV (P>0.05). Moreover, Chlorella sp. administration protected in jaundiced rats against oxidative stress, as demonstrated by reduction of intestinal lipid peroxidation, increase of the antioxidant reduced glutathione (GSH), and decrease of the oxidized glutathione (GSSG). The intestinal mucosa in control rats was atrophic with significantly decreased villous density and total mucosal thickness. Chlorella sp. caused a significant reduction in villous atrophy compared with controls.Conclusions: Chlorella sp. microalgae supplemented enteral diet has significant protective effects on intestinal mucosa barrier in obstructive jaundice, and reduces intestinal translocation of bacteria and endotoxin.

Cutoff values for central obesity in Chinese based on mesenteric fat thickness

2009-07-15

Summary: Aims: Sonographic measurement of mesenteric fat thickness (MFT) is a novel, accurate and simple tool to evaluate regional distribution of obesity. We used MFT to determine the optimal waist circumference (WC) values and associated risk factors for cardiovascular disease (CVD).Methods: 282 healthy Chinese (age 41.8±7.4 years, BMI 23.8±3.3kg/m2) was assessed. High MFT was defined as mean+1 SD of the cohort. We compared the CVD risks including fatty liver amongst subjects with normal waist, central pre-obesity and central obesity.Results: WC of 84.6cm in men and 75.7cm in women were the optimal cutoff values to predict high MFT with ROC analysis. Using WC cutoff values ≥85–90cm and ≥90cm to define central pre-obesity and obesity in men (≥75–80cm and ≥80cm in women), both central obesity and pre-obesity had higher MFT and CVD risk than those with normal waist. The frequencies of fatty liver in these 3 categories were 15.9%, 56.7% and 96.7% in men and 6.9%. 17.9% and 63.2% in women (p<0.001 for trend).Conclusion: In addition to central obesity, “central pre-obesity” identifies subjects who harbor high CVD risks, fatty liver and excess visceral fat.

Association between dietary protein and change in body composition among children (EYHS)

2009-07-15

Summary: Background & aims: Growth hormone (GH) affects body composition by a relatively reduced fat mass and increased fat free mass. The intake of protein as well as the specific amino acids arginine and lysine potently stimulate GH secretion. This study investigated associations between intakes of protein, arginine, lysine and subsequent 6-year change in body composition among 8–10-year-old children.Methods: Data of 364 children were collected from Odense, Denmark, during 1997–1998 and 6-year later as part of the European Youth Heart Study. Body mass index among children was subdivided by fat free mass index (FFMI) and fat mass index (FMI), based on skinfold measurements. Dietary intake was estimated via 24h recall. Associations between intakes of protein as well as arginine, lysine and change in FFMI and FMI were analysed by multiple linear regressions, adjusted for social economic status, puberty stage and physical activity level.Results: Among lean girls inverse associations were found between protein as well as arginine and lysine intake and change in fat mass index (β=−1.12±0.56, p=0.03, β=−1.10±0.53, p=0.04, β=−1.13±0.51, p=0.03 respectively). Furthermore among girls with a body mass index in the 5th quintile, protein intake was associated with ΔFFMI (p=0.04), and more specific when LYS intake was high, ARG intake was associated with ΔFFMI (p=0.04).Conclusion: Among girls high protein intakes may decrease body fat gain and increase fat free mass gain, depending on the available amounts and combinations of arginine and lysine.