Annals of Clinical Nutrition and Metabolism

Letter from Editor: Hyuk-Joon Lee; J Clin Nutr 2013;5(2):41-41. Published online August 31, 2013

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Aging and Nutrition: Ji Eun Park, Hyun Wook Baik; J Clin Nutr 2013;5(2):42-49. Published online August 31, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.2.42

Abstract PDF: Malnutrition is a common health problem in people older than 65 years. In older individuals, malnutrition is asso-ciated with poor clinical outcomes and even death. These individuals particularly are characterized by inadequate nutritional intake due to various factors such as medical disease, physical impairment, age-related physiological changes, and psychological and psychosocial issues. Furthermore, as the immune system ages, its function is compromised, and the aged person becomes more vul-nerable to harm and disease. Nutrition plays an important role in maintaining the vigor of the immune system, be-cause nutritional deficits and malnutrition can aggravate a diseased condition because of the weakened immune system. It is important to assess older individuals for mal-nutrition, particularly when weight loss or anorexia is observed. Nutritional status in older individuals is gen-erally assessed with the revised mini-nutritional asse-ssment short form, the malnutrition universal screening tool, and the nutritional risk screening 2002. A structured approach is essential for the management of unintended weight loss or malnutrition in older individuals. Studies have shown that oral nutritional supplementation, a well- established approach, can improve nutritional status and quality of life in older individuals. Pharmacological treat-ments, such as administration of megestrol acetate, dro-nabinol, testosterone, oxandrolone, and rh-growth hor-mone, require further investigation to assess whether they are fit for clinical application. (JKSPEN 2013;5(2):42-49)

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Nutritional Support in Renal Failure: Dong-Seok Han, Dong Ki Kim, Hyuk-Joon Lee; J Clin Nutr 2013;5(2):50-56. Published online August 31, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.2.50

Abstract PDF: The kidney is the organ responsible for clearing nitro-genous and metabolic waste from the body as well as for regulating fluid, electrolyte, and acid-base balance in the body. Because of kidney's important role in the hu-man body, renal insufficiency could exert a significant ef-fect on the nutritional and metabolic status of patients. Renal insufficiency includes a variety of areas of disease. Disease extent can be categorized as acute kidney injury (AKI), chronic kidney disease (CKD), and end-stage renal disease (ESRD) requiring renal replacement therapy (RRT). Most patients with AKI require continuous RRT. Nutritional support in renal insufficiency plays an essential role in im-proving the survival and quality of life in patients. AKI is a frequent complication affecting many critically ill pa-tients, who are in hypermetabolic state presenting with hyperglycemia, insulin resistance, hypertriglyceridemia and increased protein catabolism. The optimal nutritional man-agement of AKI includes providing adequate macro-nutrients to correct the underlying conditions and prevent ongoing loss as well as supplementing micronutrients and vitamins during RRT. As a result of the inflammatory me-diators, protein-calorie malnutrition may develop in pa-tients with CKD. Uremia also can secondarily worsen pro-tein-calorie malnutrition through the development of ano-rexia and nausea. The pre-dialysis CKD patients require low-protein diet with caloric supplementation of 35 kcal/kg/day. However, ESRD patients on dialysis should receive 1.2∼1.3 g/kg of protein daily. An appropriate nu-trition delivery, tailored to the patient's clinical presenta-tion, is important to good nutritional care. Energy require-ments must be assessed and supplementation of macro-nutrients and micronutrients based on the disease cat-egory and type of RRT must be performed. (JKSPEN 2013;5(2):50-56)

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Interactions between Medications and Nu-trients in Patients Receiving Pareneteral and Enteral Nutrition: Hyunah Kim; J Clin Nutr 2013;5(2):57-61. Published online August 31, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.2.57

Abstract PDF: Interactions between medications and nutrients are fre-quently known to occur in patients receiving enteral nu-trition (EN) and parenteral nutrition (PN). The risk of phar-macological and nutritional interactions can be significant and can have a detrimental effect on the therapeutic out-comes in patients. The purpose of this study is to provide fundamental knowledge about the identification and man-agement of clinically significant medication-nutrient inter-actions related to EN and PN. Precautions to be under-taken for medication administered with enteral nutrition. When medication is administered to a patient with EN, the following factors should be carefully considered: enteral tube feeding access site, characteristics of tube feeding, physiochemical incompatibilities related to medication dosage form, and prevention of occlusion of enteral tube feeding. Medications with special formulations should not be crushed and administered to EN patients as it can lead to higher serum concentrations and clinical toxicity. The feeding tube needs to be flushed with water before and after administering medication. Assessment of PN-medi-cation interactions should importantly take into account the stability and compatibility of medication with both two-in-one and three-in-one formulations of PN admixture. The stability of PN is affected significantly in an intra-venous (IV) lipid emulsion in a three-in-one admixture. Calcium, potassium phosphate, sodium phosphate, or magnesium should not be administered through IV Y-site with PN as these substances can cause changes in sol-ubility and may result in the formation of precipitants. Understanding the potential risks of these interactions could help in minimizing the adverse effects and optimiz-ing a patient's pharmacotherapy and specialized nutrition support. (JKSPEN 2013;5(2):57-61)

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Efficacy of Parenteral Nutrition with Intravenous L-alanyl-L-glutamine (Dipeptiven Inj) in Intensive Care Unit Patients: Hyo Jung Parkc, Su Jin Parkc, Young Mee Leec, Chi Min Park, Jeong Meen Seo; J Clin Nutr 2013;5(2):62-66. Published online August 31, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.2.62

Abstract PDF: Purpose
Intravenous glutamine may decrease complica-tions arising out of infections, hospital length of stay, and mortality in critically ill patients who require parenteral nu-trition (PN). The aim of this study was to evaluate the ef-fects of administration of L-alanyl-L-glutamine on the clin-ical outcome and serum glutamine concentrations in these patients.Methods: In a population of critically ill patients who need PN at least for 5 days due to difficulty with oral/tube feeding, selected patients after inclusion were randomized into two groups: a study group (n=3) supplied with L-alan-yl-L-glutamine administration and a control group (n=6) without it. Patients were supplied with 1.5 g/kg/day of amino acids and 20∼25 kcal/kg/day of energy. The study group received target amount of amino acids (1.5 g/kg/day) including 0.5 g/kg/day of L-alanyl-L-glutamine. The serum glutamine level and clinical outcomes were measured just before and after 4 and 8 days of PN administration.Results: We could not find out any significant differences of hospital stay, death at hospital, PN-induced complica-tions, and serum glutamine concentrations between the two groups. In the study group, the number of deaths and intensive care unit (ICU) length of stay were much higher than the control group.Conclusion: Due to the lack of randomization in this study, the benefits from parenteral glutamine supplement have not been proved. However, it is the first study to measure serum glutamine concentrations of ICU patients in Korea. Further trials are needed to determine the exact effects of parenteral glutamine administration. (JKSPEN 2013;5(2):62-66)

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Effects of SMOFlipid on Prophylaxis of Cho-lestasis in Premature Very Low Birth Weight Infants: Moon Jin Kim, Hye Jung Bae, Yoon Sook Cho, Kwi Suk Kim, Hyang Suk Kim, Hye Suk Lee, Ju Young Lee, Ee Kyung Kim, Han Suk Kim; J Clin Nutr 2013;5(2):67-75. Published online August 31, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.2.67

Abstract PDF: Purpose
Very low birth weight infants (VLBWI) are found to have a higher incidence of cholestasis due to long-term total parenteral nutrition (TPN). Although there have been some studies on relationships between omega-3 fatty acids and reduced incidence of cholestasis, the advan-tages that the fatty acids provide for premature infant dis-eases have not yet been fully understood. The aim of this study was to evaluate the advantages of SMOFlipid, a lip-id emulsion product that contains omega-3 over other lip-id emulsion products that do not.Methods: The medical records of 182 newborn (127 boys and 55 girls) were reviewed retrospectively between April 2010 and August 2012. These infants were born with a birth weight of ＜1,500 g and administered either of lipid emulsions (Intra MCT 20% or SMOFlipid) from birth to a full-feeding condition at our neonatal intensive care unit. Cholestasis is defined as serum direct bilirubin (DB) ＞1.0 mg/dL when total bilirubin (TB) is ＜5 mg/dL or DB/TB ratio is ＞20% when TB ＞5 mg/dL.Results: The incidence of cholestasis was found to be lower in the SMOFlipid group than in the medium-chain triglyceride/long chain triglyceride (MCT/LCT) group (7.3% [4/55] versus 18.9% [24/127], P=0.046). At the start of lip-id emulsion administration (day 0), the baseline bilirubin level showed no significant difference between the two groups. However, the maximum value of DB on days 7∼14 was lower in the SMOFlipid group than in the MCT/ LCT group (0.8 [0.3∼2.2] versus 1.1 [0.3∼2.8] mg/dL, P= 0.030). The DB/TB ratio was also lower in the SMOFlipid group than in the MCT/LCT group (10.2% [4.9%∼40.0%] versus 24.1% [5.1%∼62.5%], P=0.002). Conclusion: This study concluded that SMOFlipid was effective in the prevention of cholestasis in VLBWI. There-fore, omega-3-containing lipid emulsion can be highly rec-ommended in premature babies, especially in VLBWI who require TPN support. (JKSPEN 2013;5(2):67-75)

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The Adequacy of an Enteral Formula Feeding to Maintain Nutritional Status: Kyoung Hwa Yoo, In Myung Oh, Ji Eun Park, Ju Sang Park, Eun Jeong Jang, Sang Jong Park, Sang Jung Kim, Sang Woon Park, Hyun Wook Baik; J Clin Nutr 2013;5(2):76-81. Published online August 31, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.2.76

Abstract PDF: Purpose
It is a well-established fact that enteral nutrition is the preferred mode when compared with parenteral nu-trition for the purpose of recovery and maintaining nutri-tional status not only in surgical but also in chronic debili-tating patients. Further, this mode of nutrition is essential as it enhances preservation of gut mucosal integrity as well as immunity particularly in such patients. In a pro-spective multicenter clinical trial, we studied the effective-ness and safety of one specific enteral formula 'M'.Methods: We recruited 30 patients who were admitted to three hospitals (two university hospitals and one general hos-pital) in a metropolitan area for either surgery or treatment. The patients were given the enteral formula M at the dose of 25 kcal/kg/day for 7±2 days. Thereafter, we evaluated the performance and nutritional status of each patient by apply-ing subjective global assessment (SGA) scale, Karnofsky per-formance status scale, and stroke specific quality of life (SS-QOL) scale. We also measured the plasma markers spe-cific to nutritional status of such patients. In addition, we also recorded the consequent dose?response clinical symptoms such as diarrhea, abdominal pain, abdominal discomfort, bloating, nausea, and vomiting.Results: We found that the SGA scale score did not show significant change compared to the baseline score. However, both the Karnofsky performance status score and the SS-QOL score showed the tendency of improvement com-pared to the baseline score. We also found that there was a decrease in the serum markers used to signify the nutri-tional status of the patients, but this decrease was statisti-cally not significant when compared to the baseline score. Of the 30 patients enrolled for this study, 12 patients showed distinct clinical adverse symptoms. The most commonly ob-served adverse response was abdominal pain, although all other symptoms subsided spontaneously.Conclusion: We conclude that the administration of enteral formula 'M' to both perioperative and chronic debilitating pa-tients hardly elicited serious adverse response. In fact, the formula was significant in preserving the performance status and quality of life of both perioperative and chronic debilitat-ing patients. (JKSPEN 2013;5(2):76-81)

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Development of a New Nutrition Screening Tool for Use in an Acute Care Hospital: Hosun Lee, Hongjin Shim, Ji Young Jang, A Ram Jung, Soo Hee Kim, B.Pharm, Hyungmi Kim, Kyung Sik Kim, Jae Gil Lee; J Clin Nutr 2013;5(2):82-88. Published online August 31, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.2.82

Abstract PDF: Purpose
The objective of this study was to develop a new nutrition screening tool for quality improvement of the nutritional care process in an acute care hospital with a 2,000-bed capacity.Methods: To evaluate the current nutrition screening tool, we first examined 435 patients (274 men, aged 59.0±12.2 years). In the second step, the nutritional status of 387 patients (215 men, aged 57.5±13.3 years) was assessed by the scored patient-generated subjective global assess-ment (PG-SGA) tool. Variables such as age, body mass index (BMI), plasma albumin concentration, weight change, food intake change, and disease severity were analyzed to select indices for developing a new Severance nutrition screening index (SNSI).Results: The current nutrition screening tool had a poor correlation with the PG-SGA (?=0.180, P＜0.0001). The SNSI was calculated as follows: SNSI = 1.5×albumin＋1.0×BMI＋4.5×intake change＋1.5×weight loss (for al-bumin＜3.0, BMI＜20, and decreased intake and weight loss＞5% of usual body weight). The SNSI showed a sen-sitivity of 90.5%, a specificity of 90.7%, and a high corre-lation (?=0.628, P＜0.0001) with the PG-SGA.Conclusion: The SNSI appears to be a valid and useful nutrition screening tool to determine the nutritional risk of patients in acute care hospitals. (JKSPEN 2013;5(2): 82-88)

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