In this review, we have summarized various aspects as to how prenatal protein malnutrition affects development of the brain and have attempted to integrate several broad principles, concepts, and ...trends in this field in relation to our findings and other studies of malnutrition insults. Nutrition is probably the single greatest environmental influence both on the fetus and neonate, and plays a necessary role in the maturation and functional development of the central nervous system. Prenatal protein malnutrition adversely affects the developing brain in numerous ways, depending largely on its timing in relation to various developmental events in the brain and, to a lesser extent, on the type and severity of the deprivation. Many of the effects of prenatal malnutrition are permanent, though some degree of amelioration may be produced by exposure to stimulating and enriched environments. Malnutrition exerts its effects during development, not only during the so-called brain growth spurt period, but also during early organizational processes such as neurogenesis, cell migration, and differentiation. Malnutrition results in a variety of minimal brain dysfunction-type syndromes and ultimately affects attentional processes and interactions of the organism with the environment, in particular producing functional isolation from the environment, often leading to various types of learning disabilities. In malnutrition insult, we are dealing with a distributed, not focal, brain pathology and various developmental failures. Quantitative assessments show distorted relations between neurons and glia, poor formation of neuronal circuits and alterations of normal regressive events, including cell death and axonal and dendritic pruning, resulting in modified patterns of brain organization. Malnutrition insult results in deviations in normal age-related sequences of brain maturation, particularly affecting coordinated development of various cell types and, ultimately, affecting the formation of neuronal circuits and the commencing of activity of neurotransmitter cell types and, ultimately, affecting the formation of neuronal circuits and the commencing of activity of neurotransmitter systems. It is obvious that such diffuse type "lesions" can be adequately assessed only by interdisciplinary studies across a broad range of approaches, including morphological, biochemical, neurophysiological, and behavioral analyses.
Background: From the 1950s to the mid-1970s, United Nations (UN) agencies were focused on protein malnutrition as the major worldwide nutritional problem. The goal of this review is to examine this ...era of protein malnutrition, the reasons for its demise, and the aftermath. Summary: The UN Protein Advisory Group was established in 1955. International conferences were largely concerned about protein malnutrition in children. By the early 1970s, UN agencies were ringing the alarm about a ‘protein gap'. In The Lancet in 1974, Donald McLaren branded these efforts as ‘The Great Protein Fiasco', declaring that the ‘protein gap' was a fallacy. The following year, John Waterlow, the scientist who led most of the efforts on protein malnutrition, admitted that a ‘protein gap' did not exist and that young children in developing countries only needed sufficient energy intake. The emphasis on protein malnutrition waned. It is recently apparent that quality protein and essential amino acids are missing in the diet and may have adverse consequences for child growth and the reduction of child stunting. Key Messages: It may be time to re-include protein and return protein malnutrition in the global health agenda using a balanced approach that includes all protective nutrients.
Background and Aims: Malnutrition is associated with poor clinical outcomes. Whether there is a causal relationship or it merely mirrors a severe patient condition remains unclear. We examined the ...association of malnutrition with biomarkers characteristic of different pathophysiological states to better understand the underlying etiological mechanisms. Methods: We prospectively followed consecutive adult medical inpatients. Multivariable regression models were used to investigate the associations between malnutrition - as assessed using the Nutritional Risk Screening (NRS 2002) - and biomarkers linked to inflammation, stress, renal dysfunction, nutritional status and hematologic function. Results: A total of 529 patients were included. In a fully adjusted model, malnutrition was significantly associated with the inflammatory markers procalcitonin (0.20, 95% CI 0.03-0.37), proadrenomedullin (0.28, 95% CI 0.12-0.43) and albumin (-0.39, 95% CI -0.57 to -0.21), the stress marker copeptin (0.34, 95% CI 0.17-0.51), the renal function marker urea (0.23, 95% CI 0.07-0.38), the nutritional markers vitamin D25 (-0.22, 95% CI -0.41 to -0.02) and corrected calcium (0.29, 95% CI 0.10-0.49) and the hematological markers hemoglobin (-0.27, 95% CI -0.43 to -0.10) and red blood cell distribution width (0.26, 95% CI 0.07-0.44). Subgroup analysis suggested that acute malnutrition rather than chronic malnutrition was associated with elevated biomarker levels. Conclusion: Acute malnutrition was associated with a pronounced inflammatory response and an alteration in biomarkers associated with different pathophysiological states. Interventional trials are needed to prove causality.
The incidence of malnutrition disorders in chronic kidney disease (CKD) appears unchanged over time, whereas patient-care and dialysis techniques continue to progress. Despite some evidence for ...cost-effective treatments, there are numerous caveats to applying these research findings on a daily care basis. There is a sustained generation of data confirming metabolic improvement when patients control their protein intake, even at early stages of CKD. A recent protein–energy wasting nomenclature allows a simpler approach to the diagnosis and causes of malnutrition. During maintenance dialysis, optimal protein and energy intakes have been recently challenged, and there is no longer an indication to control hyperphosphatemia through diet restriction. Recent measurements of energy expenditure in dialysis patients confirm very low physical activity, which affects energy requirements. Finally, inflammation, a common state during CKD, acts on both nutrient intake and catabolism, but is not a contraindication to a nutritional intervention, as patients do respond and improve their survival as well as do noninflamed patients.
Since 2009, Médecins Sans Frontières has implemented a community management of acute malnutrition (CMAM) programme in rural Biraul block, Bihar State, India that has admitted over 10 000 severely ...malnourished children but has struggled with poor coverage and default rates. With the aim of improving programme outcomes we undertook a qualitative study to understand community perceptions of childhood undernutrition, the CMAM programme and how these affected health-seeking behaviour.
Semi-structured and narrative interviews were undertaken with families of severely malnourished children, non-undernourished children and traditional and allopathic health-care workers. Analysis of transcripts was by qualitative content analysis.
Biraul, Bihar State, India, 2010.
One hundred and fifty people were interviewed in individual or group discussions during fifty-eight interviews.
Undernutrition was not viewed as a disease; instead, local disease concepts were identified that described the clinical spectrum of undernutrition. These concepts informed perception, so caregivers were unlikely to consult health workers if children were 'only skinny'. Hindu and Muslim priests and other traditional health practitioners were more regularly consulted and perceived as easier to access than allopathic health facilities. Senior family members and village elders had significant influence on the health-seeking behaviour of parents of severely malnourished children.
The results reaffirm how health education and CMAM programmes should encompass local disease concepts, beliefs and motivations to improve awareness that undernutrition is a disease and one that can be treated. CMAM is well accepted by the community; however, programmes must do better to engage communities, including traditional healers, to enable development of a holistic approach within existing social structures.
Summary Background & aims Disease related malnutrition (under-nutrition caused by illness) is a worldwide problem in all health care settings with potentially serious consequences on a physical as ...well as a psycho-social level. In the European Union countries about 20 million patients are affected by disease related malnutrition, costing EU governments up to € 120 billion annually. The aim of this study is to calculate the total additional costs of disease related malnutrition in The Netherlands. Methods A cost-of-illness analysis was used to calculate the additional total costs of disease related malnutrition in adults (>18 years of age) for The Netherlands in 2011 in the hospital, nursing- and residential home and home care setting, expressed as an absolute monetary value as well as a percentage of the total Dutch national health expenditure and as a percentage of the total costs of the studied health care sectors in The Netherlands. Results The total additional costs of managing adult patients with disease related malnutrition were estimated to be € 1.9 billion in 2011 which equals 2.1% of the total Dutch national health expenditure and 4.9% of the total costs of the health care sectors analyzed in this study. Conclusions The results of this study show that the additional costs of disease related malnutrition in adults in The Netherlands are considerable.
Abstract The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommend that a standardized set of diagnostic characteristics be ...used to identify and document adult malnutrition in routine clinical practice. An etiologically based diagnostic nomenclature that incorporates a current understanding of the role of the inflammatory response on malnutrition's incidence, progression, and resolution is proposed. Universal use of a single set of diagnostic characteristics will facilitate malnutrition's recognition, contribute to more valid estimates of its prevalence and incidence, guide interventions, and influence expected outcomes. This standardized approach will also help to more accurately predict the human and financial burdens and costs associated with malnutrition's prevention and treatment, and further ensure the provision of high quality, cost effective nutritional care.
Summary Background & aims The confounding effect of disease on the outcomes of malnutrition using diagnosis-related groups (DRG) has never been studied in a multidisciplinary setting. This study aims ...to determine the prevalence of malnutrition in a tertiary hospital in Singapore and its impact on hospitalization outcomes and costs, controlling for DRG. Methods This prospective cohort study included a matched case control study. Subjective Global Assessment was used to assess the nutritional status on admission of 818 adults. Hospitalization outcomes over 3 years were adjusted for gender, age, ethnicity, and matched for DRG. Results Malnourished patients (29%) had longer hospital stays (6.9 ± 7.3 days vs. 4.6 ± 5.6 days, p < 0.001) and were more likely to be readmitted within 15 days (adjusted relative risk = 1.9, 95% CI 1.1–3.2, p = 0.025). Within a DRG, the mean difference between actual cost of hospitalization and the average cost for malnourished patients was greater than well-nourished patients ( p = 0.014). Mortality was higher in malnourished patients at 1 year (34% vs. 4.1 %), 2 years (42.6% vs. 6.7%) and 3 years (48.5% vs. 9.9%); p < 0.001 for all. Overall, malnutrition was a significant predictor of mortality (adjusted hazard ratio = 4.4, 95% CI 3.3–6.0, p < 0.001). Conclusions Malnutrition was evident in up to one third of the inpatients and led to poor hospitalization outcomes and survival as well as increased costs of care, even after matching for DRG. Strategies to prevent and treat malnutrition in the hospital and post-discharge are needed.
Summary Background & aims The Australasian Nutrition Care Day Survey (ANCDS) ascertained if malnutrition and poor food intake are independent risk factors for health-related outcomes in Australian ...and New Zealand hospital patients. Methods Phase 1 recorded nutritional status (Subjective Global Assessment) and 24-h food intake (0, 25, 50, 75, 100% intake). Outcomes data (Phase 2) were collected 90-days post-Phase 1 and included length of hospital stay (LOS), readmissions and in-hospital mortality. Results Of 3122 participants (47% females, 65 ± 18 years) from 56 hospitals, 32% were malnourished and 23% consumed ≤ 25% of the offered food. Malnourished patients had greater median LOS (15 days vs. 10 days, p < 0.0001) and readmissions rates (36% vs. 30%, p = 0.001). Median LOS for patients consuming ≤ 25% of the food was higher than those consuming ≤ 50% (13 vs. 11 days, p < 0.0001). The odds of 90-day in-hospital mortality were twice greater for malnourished patients (CI: 1.09–3.34, p = 0.023) and those consuming ≤ 25% of the offered food (CI: 1.13–3.51, p = 0.017), respectively. Conclusion The ANCDS establishes that malnutrition and poor food intake are independently associated with in-hospital mortality in the Australian and New Zealand acute care setting.
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