The significance of nutrition at the chronic disease patients
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The significance of nutrition at the chronic disease patients. Lubos Sobotka Department of Metabolic Care and Gerontology Medical Faculty-Charles University Hradec Kralove Czech Republic. Outlines

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The significance of nutrition at the chronic disease patients

Lubos Sobotka

Department of Metabolic Care and Gerontology

Medical Faculty-Charles University

Hradec Kralove

Czech Republic


Outlines

  • To know that chronically ill patient is at high risk of malnutrition and loss of independence

  • To be aware about crucial role of muscle tissue mass and function

  • To know that nutrition care must be an integral part of treatment process


The acutely ill older person

...is in increased need of, nutritional, rehabilitative and psychological care to avoid partial or complete loss of independence.

Sarcopenia, is a frequent comorbid situation.


Long term fasting - Mr. Levanzin

Before fasting

After fasting


Adaptation to fasting (7 days)

periphery

ketone bodies + glucose

ketone bodies 66 g

glucose 60 g

FA + glycerol

ketogenesis

AA 20 g

gluconeo-genesis

liver

fat

100 g FA + glycerol


Energy depots in a 70 kg healthy person

kg kcal

Fat 15 141.000

Protein 12 40.000

Glycogen Liver 0.2 400

Glycogen Muscle 0.5 800

Glucose 0.02 80

Hill 1992


Acutely or critically ill patient


Acute illness


Inflammation and cytokines

Cytokines

TNF, IL-1, IL-6, INF

inflammation

Insulin resistance


Inflammation promotes muscle catabolism

TNF, IL-1, IL-6, INF


Inflammation and substrate flux

inflammation

CRP, albumin

glucose

lactate

glutamin

AA - alanin

FA


Inflammation nutrition immunity and outcome

  • Inflammation is non specific defense mechanism

  • Prolonged inflammation suppress immune reaction

  • Inflammation suppress regeneration phase of healing process and supports scar formation

  • Malnutrition increase inflammatory reaction

  • Nutritional support can modify inflammatory reaction


Stress reaction

periphery

glucose 200 g

glucose 140 g

ischemic tissue

glyco-

gen

lactate

keto-

genesis

gluconeo-genesis

AA 250 g

liver

fat

FA 20 g + glycerol


Energy depots in a 70 kg healthy person

kg kcal

Fat 15 141.000

Protein 12 40.000

Glycogen Liver 0.2 400

Glycogen Muscle 0.5 800

Glucose 0.02 80

Hill 1992


Kwashiorkor

Marasmus


Endogenous protein breakdown was decreased in edematous undernourished subjects and improved after realimentation

Jahoor F et al. Am J Clin Nutr 2005


Malnutrition increase IL-6 productionIL-6 mRNA

Lyoumi S. et al. 1998


Kwashiorkor

Marasmus


Survival rate is negatively related to inflammation – CRP

Kalantak-Zadech K. et al. 2004


Survival rate is negatively related to inflammation – CRP

Qureshi AR. et al. 2002


Low grade inflammation

Decreases post-absorptive muscle protein synthesis

M. Balage et al. 2009


Muscle mass is dependent on physical activity

Immobilization due to acute illness or surgery decreases LBM, muscle mass, muscle function and muscle protein synthesis.

Bed is dangerous for elderly person as well as Ferrari car for young boy.

Claude Pichard


Lean body mass- effect of 10 days of bed rest in healthy elderly -

Change = -3.2%

kg

Kortebein P et al, JAMA 2007


Lower extremity mass (DEXA)- effect of 10 days of bedrest in healthy elderly -

Change = -6.3%

kg

Kortebein P et al, JAMA 2007


Isokinetic muscle strength - effect of 10 days of bedrest in healthy elderly -

Change = -15.6%

Nm/s

Kortebein P et al, JAMA 2007


Muscle fractional synthetic rate- effect of bedrest -

Change = -30.0%

%/h

Kortebein P et al, JAMA 2007


Consequence of acute illness

Immobility

Inflammation

Malnutrition

Loss of muscle mass

Loss of function - chronicity


Catabolic reaction

Muscle wasting

Loss of function – immobility, problems with physiotherapy, respiratory

muscle weakness, pneumonia, falls, pressure sores, etc.


Malnutrition is an independent predictor of 1-yearmortality followingacute illness

MUAC at 6 weeks

MUAC at admission

The relationship between mid-upper arm circumference (MUAC) and 1-year survival was significant (p<0.001).

Gariballa S and Forster S 2007


Malnutrition is an independent predictor of 1-yearmortality followingacute illness

MUAC at 6 weeks

MUAC at admission

The relationship between mid-upper arm circumference (MUAC) and 1-year survival was significant (p<0.01).

Gariballa S and Forster S 2007


n

No infection

116

One infection

38

>One infection 31

P

Weight (kg)

61.2 ± 1.5

58.9 ± 3.1

51.3 ± 1.7

0.0079

BMI (kg/m²)

23.8 ± 0.5

24.0 ± 1.2

21.2 ± 0.7

0.046

MAC (cm)

27.1 ± 0.4

26.7 ± 1.0

24.1 ± 0.7

0.011

TST (mm)

11.6 ± 0.5

12.9 ± 1.3

9.5 ± 0.8

0.064

BST (mm)

4.9 ± 0.3

5.9 ± 0.9

3.1 ± 0.3

0.011

Energy intake (kcal/day)

1717 ± 40

1474 ± 91

1284 ± 74

<0.001

Anthropometric variables, energy intake and nosocomial infections

BMI, body mass index; MAC, mid-arm circumference; TST, tricipital skinfold thickness; BST, bicipital skinfold thickness.

Paillaud E et al. Age and Ageing 2005


Los of independence – result of acute diseases

Topinkova 2009


Acute illness and nutrition status


Podvýživa je utajený zabiják


The relationship between nutritional status and patients’ outcomes is of particular interest in chronically critically ill patients, that is, patients who survive the life-threatening phase of critical illness have prolonged hospitalizations and many complications because of their dependence on critical care support services


Is nutrition support effective in acutely ill subjects?

Yes


Early feeding and mortality of ICU patients

ArtinianV et al.Chest, 2006


Preoperative immunonutrition and immune function

Braga et al. 2002


Nutritional supplementation during acute illnessin elderly patients

randomized, double-blind, placebo-controlled trial

Gariballa S et al. 2006


Frequency ofmalnutrition

Cost of malnutrition


Malnutrition in Swedish hospitals


Stratton et al 2005


Empty fridge study

Sieber et al 2002


Malnutrition increases mortality

Stratton et al 2006


Malnutrition increases cost of care


Role of physical activity

Physical training increases fractional synthesis rate of mixed muscle protein

Short KR et al. Am J Physiol 2004


600 kcal and 24 g protein per day

+

2 x 5 min ergometry and 30 min physiotherapy


Energy deficit

Dědková a spol 2010


Barthel index

Hegerová a spol 2010


Barthel index

Hegerová a spol 2010


Lean body mass change

Dědková a spol 2010


Role of nutrition support and physical activity


Key messages

  • There is high risk of PEM in elderly patients undergoing surgery.

  • Acute inflammation and immobility aggravate loss of muscle mass.

  • Loss of muscle mass contributed to systemic inflammatory response.

  • Muscle loss and chronic disability can predispose the elderly to a cycle of depression, anorexia, and even mental impairments.

  • Physical activity and physiotherapy should be integral part of preoperative nutrition support in the surgical and ICU elderly patients


Péče o výživu nemocných je nutností

Začněte okamžitě


Thank you


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