Anthropometric and biochemical markers for nutritional risk among residents within an Australian residential care facility

The risk of malnutrition is high among elderly population, yet few studies have measured indicators of nutritional status among Australian aged-care residents. To determine the relationship between nutritional status and bone density, hand grip strength, and the timed-up and go test, in a group of Australian aged-care residents. Anthropometric and biochemical analysis measured in subjects recruited to be part of a six month multivitamin supplementation study. One hundred and fifteen subjects participated (68% female). The mean (SD) age and body weight was 80.2(10.6) years, and 66.5(15.0) kg, respectively. Eleven percent were underweight (body mass index, BMI, <or =20.0 kg/m(2)), and 20% were obese BMI >or =30 kg/m(2)). Low serum 25-hydroxy-vitamin D (25(OH)D, <or =50 nmol/L) concentrations were found among 79% of subjects. After adjustment for body weight, there was an association between serum 25(OH)D and bone density (heel ultrasound) (r=.204, p=.027). Low serum zinc <or =10.7 micromol/L) concentrations were found among 46% of subjects; this group had a slower timed up and go time compared with those with higher zinc concentrations (n=19, 44.6 +/- 5.6 seconds vs. n=27, 30.0 +/- 3.3 seconds, p=.020). There were no associations between nutritional markers and hand grip strength. In this group, more than (3/4) of subjects had low serum 25(OH)D, and 46% had low zinc concentrations. Serum 25(OH)D was associated a lower bone density and zinc with a slower walking time. This indicates that the elderly in long term residential care facilities are at high risk for poor nutritional status, potentially increasing morbidity and mortality.

Improving health with nutritional interventions in residential aged care

In a group of Australian aged care residents, dietary energy and nutrient intakes were generally inadequate, despite sufficient energy being served. Six months of multivitamin supplementation improved nutritional status and bone quality; and six months of fortified milk consumption improved serum 25(OH)D and folate levels, and increased vitamin D and folate intakes.

A prospective cohort study of the effects of adjuvant breast cancer chemotherapy on taste function, food liking, appetite and associated nutritional outcomes

'Taste' changes are commonly reported during chemotherapy. It is unclear to what extent this relates to actual changes in taste function or to changes in appetite and food liking and how these changes affect dietary intake and nutritional status.

Effect of nutritional supplements on wound healing in home-nursed elderly: a randomized trial

 Objective: The objective was to determine whether provision of oral nutritional supplements, delivered by community nurses, could improve nutritional status and wound healing in home-nursed elderly. Methods: This was a double-blind, randomized trial in 50 elderly patients referred for wound management. Patients received 237 mL/d of 4 or 8 kJ/mL of an oral nutritional supplement for 4 wk. Nutritional status was measured with the Subjective Global Assessment and the Mini-Mental State Examination questionnaire to determine cognitive function and wound characteristics to assess healing. Differences between variables were examined with the Mann-Whitney or Student's t test for comparing two groups, one-way analysis of variance when there was more than two groups, and chi-square analysis for comparing two categorical variables. Associations between variables were examined with Pearson's correlation and regression analysis. Results: At baseline, 34% subjects were moderately malnourished and 8% were severely malnourished. In both groups, there was significantly greater improvement in Mini-Mental State Examination scores at week 4 (95% confidence interval -2.0 to -0.001, P = 0.04) and a greater decrease in the wound effusion score (95% confidence interval -2.0 to 0.0, P = 0.045). Median length of stay did not differ between groups (P > 0.05). Conclusions: Malnutrition is common in elderly patients who are nursed at home for wound management. Provision of energy- and protein-dense oral supplements by community nurses is effective in improving some indices of wound healing and cognitive function in this group. Although further study is needed to determine the effect on length of stay, the nutritional needs of this vulnerable group should not be overlooked. © 2005 Elsevier Inc. All rights reserved.

Nutritional management of gastrointestinal surgical patients in Victoria's public hospitals

Aim: Poor nutritional status has negative effects on post-operative outcomes, further compounded by surgical stress and fasting, places gastrointestinal surgery patients at high risk of malnutrition. Recent published research has challenged historic surgical nutrition practices; however, changes to practice in Australia have been slow. The aim of this study was to investigate current nutritional management of gastrointestinal surgery patients and compare this with the best practice guidelines, while exploring enablers to implementation of best practice. Methods: A 30-question telephone survey was developed to explore demographics and nutritional management of gastrointestinal surgical patients during pre-admission, inpatient stay and post-operative care. Forty-one gastrointestinal surgery dietitians were identified and contacted from 31 public hospitals in Victoria, Australia, and invited to participate. Results: Twenty-five dietitians participated in the survey (response rate 61%). Very few dietitians (12%) were funded for pre-admission clinics or outpatient clinics, and, overwhelmingly, dietitians reported not being involved in nutritional decision-making, and reported feeling unsatisfied with current nutritional management of patients. Despite half the hospitals reporting following best practice guidelines, only 22% implemented guidelines completely. There was no correlation observed between dietitian experience, department size or full-time equivalents allocated to surgery and nutritional intervention; however, the presence of a care pathway made a significant difference to the dietitian's overall satisfaction with dietetic care (P = 0.002). Conclusions: Current nutritional management of gastrointestinal surgery patients in Victorian hospitals is far from best practice. The implementation of a care pathway is the most effective way of ensuring best practice nutritional management of gastrointestinal surgical patients.

Measuring refugee malnutrition in the under-fives: pitfalls in practice

This article reviews the merit of using the World Health Organization (WHO) / National Center for Health Statistics (NCHS) references to evaluate the nutritional status of refugees and famine-affected populations and the implication of the findings for further development of Public Health Nutrition programs. Public health nutrition interventions, in order to change the nutritional status of refugees and famine affected-populations, need to be based on accurate and appropriate reference criteria in order to satisfy demands for cost-effectiveness and preserve the human right to adequate food. However, many are confused by the current practice of estimating malnutrition in complex emergencies and it appears that the use of WHO/NCHS references may not be appropriate for use under these conditions in particular, and in the third world in general. To verify this claim, we conducted a literature review. Factors to be reviewed were selected a priori. Computer-assisted searches for English-language publications in the MEDLINE database were conducted and references cited in related publications were reviewed. The literature was restricted to published papers from 1975 to 2000, which focused on malnutrition and its measurement. Findings from the literature review indicate that there is a need to develop more appropriate references that are reflective of the field of intervention. In the absence of more appropriate references, this paper presents the advantages and disadvantages of using these references and some policy recommendations.

The relationship between patient blood pathology values and patient falls in an acute-care setting : a retrospective analysis

Few studies have investigated the relationship between patient falls and patient blood pathology values, which can reveal objective information about the health and nutritional status of a patient. It could be that some abnormal values are associated with patients that fall. The objectives of the current study were to determine whether blood pathology values were different in patients who fell compared to patients who did not fall, and whether there was a difference in the type and number of currently documented risk factors for falls found for patients who fell compared to patients who did not fall. A retrospective audit of patient incident reports and medical records was conducted in an acute-care hospital for 220 patients who fell and who did not fall. Faller and non-faller patients were matched by casemix type and length of stay. Findings revealed a significant relationship between patients who fell and the variables of age, confusion status and alkaline phosphatase blood values.

Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: A randomised controlled trial

Background & Aims
Nutrients putatively implicated in pressure ulcer healing were evaluated in a clinical setting.

Methods
Sixteen inpatients with a stage 2, 3 or 4 pressure ulcer randomised to receive daily a standard hospital diet; a standard diet plus two high-protein/energy supplements; or a standard diet plus two high-protein/energy supplements containing additional arginine (9 g), vitamin C (500 mg) and zinc (30 mg). Nutritional status measurements (dietary, anthropometric and biochemical) and pressure ulcer size and severity (by PUSH tool; Pressure Ulcer Scale for Healing; 0=completely healed, 17=greatest severity) were measured weekly for 3 weeks.

Results
Patients’ age and BMI ranges were 37–92 years and 16.4–28.1 kg/m2, respectively. Baseline PUSH scores were similar between groups (8.7±0.5). Only patients receiving additional arginine, vitamin C and zinc demonstrated a clinically significant improvement in pressure ulcer healing (9.4±1.2 vs. 2.6±0.6; baseline and week 3, respectively; P<0.01). All patient groups presented with low serum albumin and zinc and elevated C-reactive protein. There were no significant changes in biochemical markers, oral dietary intake or weight in any group.

Conclusions
In this small set of patients, supplementary arginine, vitamin C and zinc significantly improved the rate of pressure ulcer healing. The results need to be confirmed in a larger study.

Food insecurity, malnutrition and mortality in Maewo and Ambae islands, Vanuatu

Context: This paper reports on findings from the ex-post evaluation of the Maewo Capacity Building project in Maewo Island, Vanuatu, which was funded by World Vision Australia.
Objectives: To examine the extent to which the infrastructure and systems left behind by the project contributed to the improvement of household food security and health and nutritional outcomes in Maewo Island, using Ambae Island as a comparator.
Setting: Two-stage cluster survey conducted from 6 to 20 July 2004, which included anthropometric measures and 4.5-year retrospective mortality data collection.
Participants: A total of 406 households in Maewo comprising 1623 people and 411 households in Ambae comprising 1799 people.
Main outcome measures: Household food insecurity, crude mortality rate (CMR), under-five mortality rate (U5MR) and malnutrition prevalence among children.
Results: The prevalence of food insecurity without hunger was estimated at 15.3%
(95% confidence interval (CI): 12.1, 19.2%) in Maewo versus 38.2% (95% CI: 33.6, 43.0%) in Ambae, while food insecurity with hunger in children did not vary by location. After controlling for the child’s age and gender, children in Maewo had higher weight-for-age and height-for-age Z-scores than children of the same age in Ambae. The CMR was lower in Maewo (CMR ¼ 0.47/10 000 per day, 95% CI: 0.39, 0.55) than in Ambae (CMR ¼ 0.59/10 000 per day, 95% CI: 0.51, 0.67) but no difference existed in U5MR. The major causes of death were similar in both locations, with frequently reported causes being malaria, acute respiratory infection and
diarrhoeal disease.
Conclusions: Project initiatives in Maewo Island have reduced the risks of mortality and malnutrition. Using a cross-sectional ‘external control group’ design, this paper demonstrates that it is possible to draw conclusions about project effectiveness where baseline data are incomplete or absent. Shifting from donor-driven evaluations to impact evaluations has greater learning value for the organisation, and greater value when reporting back to the beneficiaries about project impact and transformational
development in their community. Public health nutritionists working in the field are well versed in the collection and interpretation of anthropometric data for evaluation of nutritional interventions such as emergency feeding programmes. These same skills can be used to conduct impact evaluations, even some time after project completion, and elucidate lessons to be learned and shared. These skills can also be applied more widely to projects which impact on the longer-term nutritional status of
communities and their food security.

Mortality, malnutrition and the humanitarian response to the food crises in Lesotho

Background: At the height of the food crisis in southern Africa, the Government of Lesotho declared a state of famine and emergency in April 2002 and launched a Famine Relief Appeal for over $137 million. World Vision, in partnership with the World Food Program, became involved in December 2002 providing food aid to affected communities.
Objective: to document mortality rates, causes of death, malnutrition prevalence, and the proportion of lost pregnancies after almost three years of humanitarian response to the food crisis in Lesotho and to propose a way forward.
Design: A two-stage, 30 cluster household survey was undertaken in three districts from the 16th to the 26th of May 2005, with a sample size of 3610 people.
Results: The crude mortality rate (CMR) of 0.8/10,000/day (95%CI: 0.7-0.9). The reported CMR was significantly lower than the CMR emergency threshold (<1/10,000/day). Using 2000 as a pre-drought baseline, 38528 excess deaths occurred between 2000 and 2005. The under-five mortality rate (U5MR) of 3.2 deaths/10,000/day (95%CI: 2.8-3.6/10,000/day) was 4 times the reported CMR and 1.4 times higher the U5MR emergency threshold for sub-Saharan Africa (2.3/10,000/day). CMR was lower among food aid beneficiaries (0.68; 95%CI: 0.57-0.79) than non-beneficiaries (1.42; 95%CI: 1.13-1.70). This was also true for U5MR (2.94; 95%CI: 2.39-3.50 versus 6.44; 95%CI: 5.21-7.68). The prevalence of wasting increased from 5.4% to 12% while that of stunting declined from 45.4% to 36.2% between 2000 and 2005, but the nutritional status did not vary by beneficiary status.
Conclusion: Despite the alarming U5MR, findings suggest that the food aid program ensured survival mainly among adults. The situation could have been catastrophic in the absence of humanitarian assistance.

Globalisation, food and health in Pacific Island countries

Pacific Island countries (PICs) are experiencing an epidemic of obesity and consequent chronic diseases. Despite investment in the development of National Plans of Action for Nutrition (NPANs) and interventions to promote healthy eating and physical activity, nutritional status appears to show little improvement. This paper presents a synthesis of the findings from two research papers that were prepared for a 2003 food safety and quality meeting in Nadi, Fiji. The findings indicate that although lifestyle behaviours might be the immediate cause of dietary imbalances, greater attention should focus on omnipresent influences of globalisation as a critical element of the nutrition transition in the Pacific. In particular, those aspects of globalisation mediated through the World Trade Organization (WTO) Agreements that are placing pressures on food security and fostering increased dependence on imported food of poor nutritional quality. Rapid, significant and sustainable improvements in public health in PICs require interventions that can tackle these underlying contributors to ill health. There are opportunities to explore the use of food regulatory approaches to influence the composition, availability and accessibility of food products. Within the context of the WTO Agreements the legitimacy of food regulatory approaches will depend upon the case to demonstrate the relationship between the intervention and the protection of food security and public health nutrition. The challenges in realising these opportunities are: 1) to have the capacity to construct a case, 2) meet the technical and financial demands to administer and enforce regulatory approaches, and 3) to take advantage of opportunities available and to be able to fully participate in the international policy-making process.

24-Hour national dietary survey data : how do we interpret them most effectively?

Objective To illustrate the effect of common mistakes when using 24-hour national dietary survey data to estimate the prevalence of inadequate nutrient intakes.

Design Raw data on nutrient intake from the Australian 1995 National Nutrition Survey were adjusted for within-person variance using standard techniques and corrected for underreporting using the criteria of Goldberg et al. The distributions for six nutrients were compared with current dietary reference values from the UK, USA and Australia.

Setting A national sample of the Australian population with a 61.4% response rate.

Results Adjusting for within-person variance reduced the range of nutrient intakes to 66–80% of the raw data range and the proportion with intakes below the estimated average requirement (EAR) by up to 20%. Excluding underreporters further reduced the proportion below the EAR by up to 10%. Using the dietary reference values from different countries also resulted in some markedly different estimates. For example, the prevalence of low folate intakes ranged from <1 to 92% for adult women depending on the reference used. Except for vitamin A and protein, the prevalence of low intakes was invariably higher for women than for men.

Conclusions Estimates of the prevalence of low nutrient intakes based on raw 24-hour survey data are invariably misleading. However, even after adjustment for within-person variance and underreporting, estimates of the prevalence of low nutrient intakes may still be misleading unless interpreted in the light of the reference criteria used and supported by relevant biochemical and physiological measures of nutritional status.

Energy expenditure and the body cell mass in Cystic Fibrosis

Poor nutritional status in patients with cystic fibrosis (CF) is associated with severe lung disease, and possible causative factors include inadequate intake, malabsorption, and increased energy requirements. Body cell mass (which can be quantified by measurement of total body potassium) provides an ideal standard for measurements of energy expenditure. The aim of this study was to compare resting energy expenditure (REE) in patients with CF with both predicted values and age-matched healthy children and to    determine whether REE was related to either nutritional status or pulmonary function. REE was measured by indirect calorimetry and body cell mass by scanning with total body potassium in 30 patients with CF (12 male, mean AGE = 13.07 ± 0.55 y) and 18 healthy children (six male, mean AGE = 12.56 ± 1.25 y). Nutritional status was expressed as a percentage of predicted total body potassium. Lung function was measured in the CF group by spirometry and expressed as the percentage of predicted forced expiratory volume in 1 s. Mean REE was significantly increased in the patients with CF compared with healthy children (119.3 ± 3.1% predicted versus 103.6 ± 5% predicted, P < 0.001) and, using multiple regression techniques, REE for total body potassium was significantly increased in patients with CF (P = 0.0001). There was no relation between REE and nutritional status or pulmonary disease status in the CF group. In conclusion, REE is increased in children and adolescents with CF but is not directly related to nutritional status or pulmonary disease.

Nutrition and mental health research in Australia and New Zealand: A review of progress and directions for the future

This review summarises nutrition and mental health research in Australia and New Zealand between 1986 and 2006. The method used to identify papers for inclusion was a search of computerised databases: Medline, Cinahl and Meditext 1986–2006, with subsequent bibliographical review. Key search words were nutrition, diet, mental disorder, mental illness, weight, physical health, Australia and New Zealand. Inclusion criteria included: English language, original data in peer reviewed journals, and examination of some component of nutrition in people with a mental illness. The review of thirteen papers found that the evidence base for dietetic practice in mental health has developed through small assessment and interventional research, often with multidisciplinary collaboration. Future research should include quality and outcome measures with intersectoral partnerships. Dietitians are well positioned to lead and participate in mental health research and to implement research findings to improve the nutritional status of this vulnerable group.

Associations of maternal long-chain polyunsaturated fatty acids, methyl mercury, and infant development in the Seychelles Child Development Nutrition Study

Fish consumption during gestation can provide the fetus with long-chain polyunsaturated fatty acids (LCPUFA) and other nutrients essential for growth and development of the brain. However, fish consumption also exposes the fetus to the neurotoxicant, methyl mercury (MeHg). We studied the association between these fetal exposures and early child development in the Seychelles Child Development Nutrition Study (SCDNS). Specifically, we examined a priori models of Ω-3 and Ω-6 LCPUFA measures in maternal serum to test the hypothesis that these LCPUFA families before or after adjusting for prenatal MeHg exposure would reveal associations with child development assessed by the BSID-II at ages 9 and 30 months. There were 229 children with complete outcome and covariate data available for analysis. At 9 months, the PDI was positively associated with total Ω-3 LCPUFA and negatively associated with the ratio of Ω-6/Ω-3 LCPUFA. These associations were stronger in models adjusted for prenatal MeHg exposure. Secondary models suggested that the MeHg effect at 9 months varied by the ratio of Ω-6/Ω-3 LCPUFA. There were no significant associations between LCPUFA measures and the PDI at 30 months. There were significant adverse associations, however, between prenatal MeHg and the 30-month PDI when the LCPUFA measures were included in the regression analysis. The BSID-II mental developmental index (MDI) was not associated with any exposure variable. These data support the potential importance to child development of prenatal availability of Ω-3 LCPUFA present in fish and of LCPUFA in the overall diet. Furthermore, they indicate that the beneficial effects of LCPUFA can obscure the determination of adverse effects of prenatal MeHg exposure in longitudinal observational studies.