ESPEN Guidelines on Enteral Nutrition: Geriatrics

Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Evaluation of sugar maple dieback in the Upper Great Lakes region and development of a forest health youth education program

Acer saccharum Marsh., is one of the most valuable trees in the northern hardwood forests. Severe dieback was recently reported by area foresters in the western Upper Great Lakes Region. Sugar Maple has had a history of dieback over the last 100 years throughout its range and different variables have been identified as being the predisposing and inciting factors in different regions at different times. Some of the most common factors attributed to previous maple dieback episodes were insect defoliation outbreaks, inadequate precipitation, poor soils, atmospheric deposition, fungal pathogens, poor management, or a combination of these. The current sugar maple dieback was evaluated to determine the etiology, severity, and change in dieback on both industry and public lands. A network of 120 sugar maple health evaluation plots was established in the Upper Peninsula, Michigan, northern Wisconsin, and eastern Minnesota and evaluated annually from 2009-2012. Mean sugar maple crown dieback between 2009-2012 was 12.4% (ranging from 0.8-75.5%) across the region. Overall, during the sampling period, mean dieback decreased by 5% but individual plots and trees continued to decline. Relationships were examined between sugar maple dieback and growth, habitat conditions, ownership, climate, soil, foliage nutrients, and the maple pathogen sapstreak. The only statistically significant factor was found to be a high level of forest floor impacts due to exotic earthworm activity. Sugar maple on soils with lower pH had less earthworm impacts, less dieback, and higher growth rates than those on soils more favorable to earthworms. Nutritional status of foliage and soil was correlated with dieback and growth suggesting perturbation of nutrient cycling may be predisposing or contributing to dieback. The previous winter's snowfall totals, length of stay on the ground, and number of days with freezing temperatures had a significant positive relationship to sugar maple growth rates. Sapstreak disease, Ceratocystis virescens, may be contributing to dieback in some stands but was not related to the amount of dieback in the region. The ultimate goal of this research is to help forest managers in the Great Lakes Region prevent, anticipate, reduce, and/or salvage stands with dieback and loss in the future. An improved understanding of the complex etiology associated with sugar maple dieback in the Upper Great Lakes Region is necessary to make appropriate silvicultural decisions. Forest Health education helps increase awareness and proactive forest management in the face of changing forest ecosystems. Lessons are included to assist educators in incorporating forest health into standard biological disciplines at the secondary school curricula.

A practical posture for hand grip dynamometry in the clinical setting

The optimal testing position for hand grip strength, which is a useful functional measure of nutritional status, is open to debate. We therefore examined the systematic difference between different postures in order to establish a methodology that is clinically relevant, easy to perform and reproducible.

Xenobiotic Metabolism Genes and Clubfoot

Idiopathic or isolated clubfoot is a common orthopedic birth defect that affects approximately 135,000 children worldwide. It is characterized by equinus, varus and adductus deformities of the ankle and foot. Correction of clubfoot involves months of serial manipulations, castings and bracing, with surgical correction needed in forty percent of cases. Multifactorial etiology has been suggested in numerous studies with both environmental and genetic factors playing an etiologic role. Maternal smoking during pregnancy is the only common environmental factor that has consistently been shown to increase the risk for clubfoot. Moreover, a positive family history of clubfoot and maternal smoking increases the risk of clubfoot twenty fold. These findings suggest that genetic variation in smoking metabolism genes may increase susceptibility to clubfoot. Based on this reasoning, we interrogated eight candidate genes, chosen based on their involvement in phase 1 and 2 cigarette smoke metabolism. Twenty-two SNPs and two null alleles in eight genes (CYP1A1, CYP1A2, CYP1B1, CYP2A6, EPHX1, NAT2, GSTM1 and GSTT1) were genotyped in a dataset composed of nonHispanic white and Hispanic multiplex and simplex families. Only one SNP in CYP1A1, rs1048943, had significantly altered transmission in the aggregate and multiplex NHW datasets (p=0.003 and p=0.009). Perturbation of CYP1A1 by rs1048943 polymorphism causes an increase in the amount of harmful, adduct forming metabolic intermediates. A significant gene interaction between EPHX1 and NAT2 was also found (p=0.007). This interaction may affect the metabolism of harmful metabolic intermediates. Additionally, marginal interactions were found for other xenobiotic genes and these interactions may play a contributory role in clubfoot. Importantly, for CYP1A2, significant maternal (p=0.03; RR=1.24; 95% CI: 1.04-1.44) and fetal (p=0.01; RR=1.33; 95% CI: 1.13-1.54) genotypic effects were identified suggesting that both maternal and fetal genotypes impact normal limb development. No association was found for maternal smoking status and tobacco metabolism genes. Together, these results suggest that xenobiotic metabolism genes may play a contributory role in the etiology of clubfoot regardless of maternal smoking status and may impact foot development through perturbation of tobacco metabolic pathways.

Exploring the Association Between Household Food Insecurity, Parental Self-Efficacy, and Fruit and Vegetable Parenting Practices Among Parents of 5- to 8-Year-Old Overweight Children

Background: Food insecurity may negatively impact children’s nutritional status by affecting parenting quality. Because parents have a strong influence on their children’s eating and food choices, examining the effects of food insecurity on parenting may provide important insights into obesity prevention efforts. Objectives: This study explored whether food insecurity was associated with parental self-efficacy and parenting practices related to fruit and vegetable consumption. Methods: Secondary analysis was performed using baseline data from 31 mothers of 5-8 year old overweight or obese children who had participated in a pilot obesity treatment program. Household food security status, fruit and vegetable parental self-efficacy (modeling/socialization, planning/encouraging and availability/accessibility) and fruit and vegetable parenting practices (structure, responsiveness, non-directive control, and external control) were assessed using validated measures. Students' t-test investigated differences in subscales by food security status. Results: There were no significant differences in fruit and vegetable parenting practices and parental self-efficacy between food secure and insecure groups. There was a trend towards a decrease in parental self-efficacy for making fruit and vegetables available in the home among food insecure parents (p=.06). Conclusions: In this small sample no significant associations were found between food insecurity and fruit and vegetable parenting practices and parental self-efficacy. However, the trend observed in this exploratory analysis supports further hypothesis-driven research with a larger sample size able to detect more subtle differences.

Piriformospora indica and Sebacina vermifera increase growth performance at the expense of herbivore resistance in Nicotiana attenuata

A Sebacinales species was recovered from a clone library made from a pooled rhizosphere sample of Nicotiana attenuata plants from 14 native populations. Axenic cultures of the related species, Piriformospora indica and Sebacina vermifera, were used to examine their effects on plant performance. Inoculation of N. attenuata seeds with either fungus species stimulated seed germination and increased growth and stalk elongation. S. vermifera inoculated plants flowered earlier, produced more flowers and matured more seed capsules than did non-inoculated plants. Jasmonate treatment during rosette-stage growth, which slows growth and elicits herbivore resistance traits, erased differences in vegetative, but not reproductive performance resulting from S. vermifera inoculation. Total nitrogen and phosphorous contents did not differ between inoculated and control plants, suggesting that the performance benefits of fungal inoculation did not result from improvements in nutritional status. Since the expression of trypsin proteinase inhibitors (TPI), defensive proteins which confer resistance to attack from Manduca sexta larvae, incur significant growth and fitness costs for the plant, we examined the effect of S. vermifera inoculation on herbivore resistance and TPI activity. After 10 days of feeding on S. vermifera-inoculated plants, larval mass was 46% higher and TPI activity was 48% lower than that on non-inoculated plants. These results suggest that Sebacina spp. may interfere with defense signaling and allow plants to increase growth rates at the expense of herbivore resistance mediated by TPIs.

["Not to be taken lightly"].

A 78 year old patient with type 2 diabetes mellitus was hospitalized because of weakness and poor nutritional status. For several years, he suffered from an unintended weight loss and chronic, pulpy diarrhea. On examination, we found a severe loss of muscle and fat tissue as well as difficulty swallowing. An adequate nutritional therapy with combined parenteral and enteral nutrition was implemented under regular monitoring of electrolytes and volume status, under which the state of health improved noticeably, while steatorrhea improved under substitution of pancreatic enzymes.

Home parenteral nutrition is beneficial in systemic sclerosis patients with gastrointestinal dysfunction

OBJECTIVES To assess 12-month changes in nutritional status and quality of life (QoL) in systemic sclerosis (SSc) patients requiring home parenteral nutrition (HPN). METHOD We conducted a retrospective, single-centre database analysis of SSc patients regarding a 12-month period of HPN at an interdisciplinary University Unit/team for nutrition and rheumatic diseases. Nutritional status was analysed by nutritional risk screening (NRS) and body mass index (BMI). QoL was evaluated using Short-Form Health Survey (SF-36) questionnaires. RESULTS Between 2008 and 2013, daily nocturnal HPN was initiated in five consecutive SSc patients (four females and one male, mean age 62.2 years) suffering severe malnutrition due to gastrointestinal tract (GIT) involvement. After 12 months of HPN, the mean NRS score decreased from 4.4 (range 4-5) to 1.4 (range 1-2), the mean BMI increased from 19.1 (range 17.4-20.3) to 21.0 kg/m(2) (range 18.3-23.4). QoL improved in all patients, reflected by the summary of physical components with 33.92 points before vs. 67.72 points after 12 months of HPN, and the summary of mental components with 49.66 points before vs. 89.27 points after 12 months of HPN. Two patients suffered one catheter-related infection each with subsequent surgical removal and reinsertion. CONCLUSIONS HPN is a feasible method for improving anthropometric parameters and QoL in SSc patients severely affected by GIT dysfunction. We recommend HPN in malnourished, catabolic SSc patients unable to otherwise maintain or improve their nutritional status.

Masticatory function and nutrition in old age

Nowadays, many people retain their natural teeth until late in life as a result of the large success of preventive strategies. However, there is still a very high prevalence of edentulism especially in elderly patients and many of these patients are provided with inadequate dental prostheses. In addition, many elderly citizens suffer from systemic diseases leading to increased drug prescription with age. This may have direct or indirect negative effects on the health and integrity of oral tissues like teeth, mucosa or muscles. There is growing evidence that a close interaction between the general medical condition and oral health exists. From a dental point of view, the chewing ability and capacity and its interaction with the nutritional status seem to be especially important. For example, complete denture wearers present a significant oral disability, which often leads to a gradual deterioration of their individual dietary habits. The improvement of maximum bite force and chewing efficiency may be an important prerequisite for an adequate nutrition. Those functional parameters can often be improved by providing functional dental prostheses or by stabilizing complete dentures with endosseous implants. Nevertheless, an improvement of the nutritional status can only be achieved through a close collaboration with dieticians or clinical nutritionists.

A constellation of factors associated with premature births among African American women

A cohort, cross-sectional, historical study design was used to study factors related to spontaneous premature birth outcomes among African American women. The cohort consisted of 4,294 mothers drawn from the 1988 National Maternal and Infant Health Survey conducted by the National Center for Health Statistics. The objectives of the study were: (1) to examine the distribution of gestational ages of African American infants for selected variables reported for their families and (2) to describe risk factors associated with birth at 20–31 weeks of gestational age and at 32–36 weeks of gestational age. Risk factors examined include maternal age, maternal marital status, maternal living arrangements, maternal education, maternal work status, household income, gestational bleeding, month prenatal began, adequacy of prenatal care, parity, previous viable preterm birth, and behavioral factors of attitude toward pregnancy, smoking, drug, and alcohol use during pregnancy. Frequency distributions, cross tabulations, stratified analysis, and logistic regression analysis were used. ^ Risk factors associated with a 50 percent or more increase in preterm birth were cocaine use, low maternal education, teenaged mother, prenatal care deficits or overuse, and bleeding during the second half of pregnancy. The other risk factors of not living with the baby's father, smoking cigarettes and having a mistimed pregnancy carried statistically significance but lower strength of association. ^ Health care services, educational systems, and community organizations can develop and evaluate comprehensive health education and information campaigns that address preventable risk factors during pregnancy. Although preterm birth cannot always be prevented, preconception care can help identify and modify maternal risk and promote optimum health before conception. Quality care should include continued risk assessment, health promotion, and interventions. ^

Early life risk factors and puberty implications for cancer prevention

Earlier age at puberty is a known risk factor for breast cancer and suspected to influence prostate cancer; yet few studies have assessed early life risk factors for puberty. The overall objectives was to determine the relationship between birth-weight-for-gestational-age (BWGA), weight gain in infancy and pubertal status in girls and boys at 10.8 and 11.8 years and who were born of preeclamptic (PE) and normotensive (NT) mothers. Data for this study were collected from hospital and public health medical records and at a follow-up visit at 10.8 and 11.8 years for girls and boys, respectively. We used stratified analysis and multivariable logistic regression modeling to assess effect measure modifier and to determine the relationship between BWGA, weight gain in infancy and childhood and pubertal status, respectively. ^ There was no difference in the relationship between BWGA and pubertal status by maternal PE status for girls and boys; however, there was a non-significant increase in the odds of having been born small-for-gestational-age (SGA) in girls who were pubertal for breast or pubic hair Tanner stage 2+ compared to those who B1 or PH1. In contrast, boys who were pubertal for genital and pubic hair Tanner stage 2+ had lower odds of having been born SGA than those who were prepubertal for G1 or PH1. ^ In girls who were pubertal for breast development, the odds of having gained one additional unit SD for weight was highest between 3 to 6 months and 6-12 months for those who were B2+ vs. B1. For pubic hair development, weight gain between 6-12 months had the greatest effect for girls of PE mothers only. In boys, there were no statistically significant associations between weight gain and genital Tanner stage at any of the intervals; however, weight gain between 3-6 months did affect pubic hair tanner stage in boys of NT mothers. This study provide important evidence regarding the role of SGA and weight gain at specific age intervals on puberty; however, larger studies need to shed light on modifiable exposures for behavioral interventions in pregnancy, postpartum and in childhood.^

The association between CD4+ lymphocyte count and measures of body composition in HIV-infected men

Purpose. This project was designed to describe the association between wasting and CD4 cell counts in HIV-infected men in order to better understand the role of wasting in progression of HIV infection.^ Methods. Baseline and prevalence data were collected from a cross-sectional survey of 278 HIV-infected men seen at the Houston Veterans Affairs Medical Center Special Medicine Clinic, from June 1, 1991 to January 1, 1994. A follow-up study was conducted among those at risk, to investigate the incidence of wasting and the association between wasting and low CD4 cell counts. Wasting was described by four methods. Z-scores for age-, sex-, and height-adjusted weight; sex-, and age-adjusted mid-arm muscle circumference (MAMC); and fat-free mass; and the ratio of extra-cellular mass (ECM) to body-cell mass (BCM) $>$ 1.20. FFM, ECM, and BCM were estimated from bioelectrical impedance analysis. MAMC was calculated from triceps skinfold and mid-arm circumference. The relationship between wasting and covariates was examined with logistic regression in the cross-sectional study, and with Poisson regression in the follow-up study. The association between death and wasting was examined with Cox's regression.^ Results. The prevalence of wasting ranged from 5% (weight and ECM:BCM) to almost 14% (MAMC and FFM) among the 278 men examined. The odds of wasting, associated with baseline CD4 cell count $<$200, was significant for each method but weight, and ranged from 4.6 to 12.7. Use of antiviral therapy was significantly protective of MAMC, FFM and ECM:BCM (OR $\approx$ 0.2), whereas the need for antibacterial therapy was a risk (OR 3.1, 95% CI 1.1-8.7). The average incidence of wasting ranged from 4 to 16 per 100 person-years among the approximately 145 men followed for 160 person-years. Low CD4 cell count seemed to increase the risk of wasting, but statistical significance was not reached. The effect of the small sample size on the power to detect a significant association should be considered. Wasting, by MAMC and FFM, was significantly associated with death, after adjusting for baseline serum albumin concentration and CD4 cell count.^ Conclusions. Wasting by MAMC and FFM were strongly associated with baseline CD4 cell counts in both the prevalence and incidence study and strong predictors of death. Of the two methods, MAMC is convenient, has available reference population data, may be the most appropriate for assessing the nutritional status of HIV-infected men. ^

THE BACON CHOW STUDY: THE RELATIONSHIP BETWEEN INFECTIOUS ILLNESS AND GROWTH OF INFANTS

Multiple dietary deficiencies and high rates of infectious illness are major health problems leading to malnutrition and limitation of growth of children in developing countries. Longitudinal studies which provide information on illness incidence and growth velocity are needed in order to untangle the complex interrelationship between nutrition, illness and growth. From 1967 to 1973, researchers led by Dr. Bacon Chow of the Johns Hopkins University School of Hygiene undertook a quasi-experimental prospective study in Suilin Township, Taiwan to determine the effects of a nutritional supplement to the diets of pregnant and lactating women on the growth, development and resistance to disease of their offspring. This dissertation presents results from the analysis of infant morbidity and postnatal growth.^ Maternal nutritional supplementation has no apparent effect on the postnatal growth or morbidity of infants. Significant sex differences exist in growth response to illness and in illness susceptibility. Male infants have more diarrhea and upper respiratory illness. Respiratory illness is positively associated with growth rate in weight in the first semester of life. Diarrhea is significantly negatively associated with growth in length in the second semester. Small-for-date infants are more susceptible to illness in general and have a different pattern of growth response than large-for-date infants.^ Principal components analysis of illness data is shown to be an effective technique for making more precise use of ambiguous morbidity data. Multiple regression with component scores is an accurate method for estimating variance in growth rate predicted by indepenent illness variables. A model is advanced in which initial postnatal growth rate determines subsequent susceptibility to nutritional stress and infection. Initial growth rate is a function of prenatal nutrition, but is not significantly affected by maternal supplementation during gestation or lactation. Critical evaluation is made of nutritional supplementation programs which do not afford disease control.^

Predictors of HIV-1 slow progression among vertically infected children in Botswana

HIV-1 infected children display a highly variable rate of progression to AIDS. Data about reasons underlying the variable progression to AIDS among vertically-infected children is sparse, and the few studies that have examined this important question have almost exclusively been done in the developed world. This is despite the fact that Sub-Saharan Africa is home to over 90% of all HIV infected children around the world.^ The main objective of this study was to examine predictors of HIV-1 slow progression among vertically infected children in Botswana, using a case control design. Cases (slow progressors) and controls (rapid progressors) were drawn from medical records of HIV-1 infected children being followed up for routine care and treatment at the BBCCCOE between February 2003 and February 2011. Univariate and Multivariate Logistic Regression Analyses were performed to identify independent predictors of slow disease progression and control for confounding respectively. ^ The study population comprised of 152 cases and 201 controls with ages ranging from 6 months to 16 years at baseline. Low baseline HIV-1 RNA viral load was the strongest independent predictor of slow progression (adjusted OR = 5.52, 95% CI = 2.75-11.07; P <0.001). Other independent predictors of slow disease progression identified were: lack of history of PMTCT with single dose Nevirapine plus Zidovudine (adjusted OR = 4.45, 95% CI = 1.45-13.69; P = 0.009) and maternal vital status (alive) (adjusted OR = 2.46, 95% CI = 1.51-4.01; P < 0.00 ).^ The results of this study may help clinicians and policy-makers in resource-limited settings to identify, at baseline, which children are at highest risk of rapid progression to AIDS and thus prioritize them for immediate intervention with HAART and other measures that would mitigate disease progression. At the same time HAART may be delayed among children who are at lower risk of disease progression. This would enable the highly affected, yet impoverished, Sub-Saharan African countries to use their scarce resources more efficiently which may in turn ensure that their National Antiretroviral Therapy Programs become more sustainable. Delaying HAART among the low-risk children would also lower the occurrence of adverse drug reactions associated with antiretroviral drugs exposure.^ Keywords. Slow Progressors, Rapid Progressors, HIV-1, Predictors, Children, Vertical Transmission, Sub-Saharan Africa^

Gestión de la fertilidad de suelos y la nutrición de plantaciones de teca (Tectona grandis L.f.) en América Central

La teca (Tectona grandis L.f.) ha sido tradicionalmente considerada como una madera preciosa en los países del SE Asiático, de donde es originaria, pero durante las últimas décadas ha alcanzado especial relevancia en el sector internacional de las maderas tropicales duras de buena calidad. La especie ha sido ampliamente establecida en América Central, donde tiene una gran importancia socioeconómica, tanto por el impacto de las grandes empresas multinacionales que gestionan grandes plantaciones en la región, como por el gran número de pequeños y medianos propietarios que han elegido esta especie para reforestar sus tierras. Pese a la gran importancia de esta especie, se ha desarrollado relativamente poca investigación acerca de su nutrición y de la gestión del suelo necesaria para su establecimiento y mantenimiento en condiciones sostenibles y productivas. En la presente Tesis Doctoral, tras realizar una amplia revisión bibliográfica, se caracterizan los suelos y la nutrición de las plantaciones de teca en América Central y se proponen varias herramientas para la mejora de su gestión. Las plantaciones de teca de América Central presentan habitualmente deficiencias de K y P, además de algunos problemas de acidez ocasionales. Estos se originan, principalmente, por la mala selección de sitio que se realizó en las últimas dos décadas del siglo XX y por el establecimiento de plantaciones de teca por pequeños propietarios en terrenos que no tienen características propicias para la especie. Además, estos problemas comunes relativos a la baja disponibilidad de P y de K en el suelo son causantes de las relativamente bajas concentraciones foliares de estos elementos (0,88±0,07% K y 0,16±0,04% P) encontradas en plantaciones de teca características de la región. Se presentan varios modelos estadísticos que permiten a los gestores: (a) usarlos como referencia para la interpretación de análisis foliares, ya que ofrecen valores que se consideran característicos de plantaciones de teca con un buen estado nutricional; (b) estimar la cantidad de nutrientes acumulados en la biomasa aérea de sus plantaciones y, sobre todo, su extracción a través de la madera en un aprovechamiento forestal, bien sea una clara o la corta final. La gran acumulación de N, P y K en plantaciones de teca ha de ser considerada como un factor fundamental en su gestión. Además, P y K adquieren mayor relevancia aún ya que su extracción del sistema a través de la madera y su escasa disponibilidad en los suelos hacen que se presente un importante desequilibrio que pone en riesgo la sostenibilidad del sistema. En ese sentido, cambiar la época de cosecha, de la actual (en Enero-Mayo) a Septiembre o Diciembre, puede reducir entre un 24 y un 28% la salida de N asociada a la extracción de madera, un 29% la de P y entre un 14 y un 43% la de K. Se estima que la concentración foliar de P es un factor limitante de la productividad de plantaciones de teca en América Central, proponiéndose un nivel crítico de 0,125%. Además, la teca presenta una tolerancia muy baja a suelos salinos, tendencia que no había sido señalada hasta el momento, siendo muy alta la probabilidad de que la plantación tenga un crecimiento lento o muy lento cuando la Saturación de Na es mayor de 1,1%. Por otro lado, se confirma que K es uno de los elementos clave en la nutrición de las plantaciones de teca en la región centroamericana, proponiéndose un nivel crítico provisional de 3,09% para la Saturación de K, por encima del cual es muy probable que la plantación tenga un crecimiento muy alto. Se ha comprobado que las técnicas estadísticas de análisis multivariante pueden ser usadas como herramientas para agrupar los rodales en base a sus similitudes en cuanto a la fertilidad del suelo y mejorar así el diseño de planes de fertilización en plantaciones con una superficie relativamente grande. De esta manera, se pueden ajustar planes de fertilización más eficientes a escala de grupos de rodales, como un primer paso hacia la selvicultura de precisión, intensificando y diversificando la gestión en función de las diferencias edáficas. Finalmente, aunque los análisis foliares y de suelos indiquen la existencia de deficiencias nutricionales, la fertilización de las plantaciones no siempre va a producir efectos positivos sobre su crecimiento si no se diseña adecuadamente teniendo en cuenta varios factores que pueden estar influyendo negativamente en dicha respuesta, como la densidad de las plantaciones (sinergias con la programación de los clareos y claras) y la elección de la dosis y del producto a aplicar (habitualmente dosis bajas de N-P-K en lugar de incluir otros nutrientes como Mg, B y Zn o usar otros productos como micorrizas, biofertilizantes etc…). ABSTRACT Teak (Tectona grandis L.f.) has been traditionally considered as a precious wood in SE Asia, where it is indigenous. However, during recent decades the species has reached worldwide relevance in the tropical high quality hardwood sector. Teak has been widely established in Central America, where it has become a key species in the forest sector due to its socioeconomic impact, either because of the big-scale plantations of transnational companies and the abundant small-scale plantations established by many farmers. Despite the relevance of the species, little research has been carried out regarding its soil fertility and nutrition management, a key issue both for sustainability and productivity. The present Thesis performs a literature review to this respect, characterize the soil fertility and the nutrition of teak plantations of Central America and propose several management tools. Soil deficiencies of K and P are usually found in teak plantations in Central America, in addition to occasional acidity problems. These problems are mainly derived of (a) a poor site selection performed during 80s and 90s; and (b) small-scale plantations by farmers in sites which are not adequate for the species. These common soil fertility problems related with P and K soil availability are probably the cause of the relatively low P and K foliar concentration (0,88±0,07% K y 0,16±0,04% P) found in representative teak plantations of the region. Several statistical models are proposed, which allow forest managers to: (a) use them as a reference for foliar analysis interpretation, as they show values considered as representative for teak plantations with an adequate nutritional status in the region; (b) estimate the amount of nutrients accumulated in the aerial biomass of the plantations and, especially, the amount of them which are extracted from the systems as wood is harvested in thinning or final clearcuts. The accumulation of N, P and K result in a key factor for teak management in the region. This turns out to be especially relevant for the P and K because their high output rate by timber extraction and the low soil availability result in an important unbalance which constitutes a risk regarding the sustainability of the system. To this respect, modifying the harvesting time from the usual right now (January-May, business as usual scenario) to September or December (proposed alternatives) can reduce between 24 and 28% the N output associated to timber extraction, 29% the P output and between 14 and 43% the K. Foliar P concentration is a main limiting factor for teak plantations productivity in Central America and a 0.125% critical level is proposed. In addition, the results show a very low tolerance for soil salinity, tendency which was not previously reported. Hence, the probability of teak plantations to have low or very low Site Index is high when Na Saturation is higher than 1.1%. On the other hand, K is confirmed as one of the key nutrients regarding teak nutrition in Central America and a 3.09% provisional critical level is proposed for K Saturation; when values are above this level the probability of having very high Site Index is high. Multivariate statistical analyses have been successfully tested to be used as tools to group forest stands according to their soil fertility similarities. Hence, more efficient fertilization plans can be designed for each group of stands, intensifying and diversifying nutritional management according to soil fertility differences. This methodology, which is considered as a first step towards precision forestry, is regarded as helpful tool to design fertilization plans in big scale plantations. Finally, even though foliar and soil analysis would point out some nutritional deficiencies in a forest stand, the results show how the fertilization is not always going to have a positive effect over forest growth if it is not adequately designed. Some factors have been identified as determinants of tree response to fertilization: density (synergisms between fertilization and thinning scheduling) and the appropriate selection of dosages and product (usually low dosages are applied and N-P-K is preferred instead of applying other nutrients such as Mg, B or Zn or using other alternatives such as mycorrhizas or biofertilizers).