The significance of nutrition at the chronic disease patients

1. 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

2. 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

3. 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.

4. Long term fasting - Mr. Levanzin Before fasting After fasting

5. 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

6. 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

8. Acutely or critically ill patient

9. Acute illness

10. Inflammation and cytokines Cytokines TNF, IL-1, IL-6, INF inflammation Insulin resistance

11. Inflammation promotes muscle catabolism TNF, IL-1, IL-6, INF

12. Inflammation and substrate flux inflammation CRP, albumin glucose lactate glutamin AA - alanin FA

13. 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

14. 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

15. 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

16. Kwashiorkor Marasmus

17. Endogenous protein breakdown was decreased in edematous undernourished subjects and improved after realimentation Jahoor F et al. Am J Clin Nutr 2005

18. Malnutrition increase IL-6 productionIL-6 mRNA Lyoumi S. et al. 1998

19. Kwashiorkor Marasmus

20. Survival rate is negatively related to inflammation – CRP Kalantak-Zadech K. et al. 2004

21. Survival rate is negatively related to inflammation – CRP Qureshi AR. et al. 2002

22. Low grade inflammation Decreases post-absorptive muscle protein synthesis M. Balage et al. 2009

23. 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

24. Lean body mass- effect of 10 days of bed rest in healthy elderly - Change = -3.2% kg Kortebein P et al, JAMA 2007

25. Lower extremity mass (DEXA)- effect of 10 days of bedrest in healthy elderly - Change = -6.3% kg Kortebein P et al, JAMA 2007

26. Isokinetic muscle strength - effect of 10 days of bedrest in healthy elderly - Change = -15.6% Nm/s Kortebein P et al, JAMA 2007

27. Muscle fractional synthetic rate- effect of bedrest - Change = -30.0% %/h Kortebein P et al, JAMA 2007

28. Consequence of acute illness Immobility Inflammation Malnutrition Loss of muscle mass Loss of function - chronicity

29. Catabolic reaction Muscle wasting Loss of function – immobility, problems with physiotherapy, respiratory muscle weakness, pneumonia, falls, pressure sores, etc.

30. 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

31. 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

32. 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

35. Los of independence – result of acute diseases Topinkova 2009

36. Acute illness and nutrition status

37. Podvýživa je utajený zabiják

38. 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

39. Is nutrition support effective in acutely ill subjects? Yes

40. Early feeding and mortality of ICU patients ArtinianV et al.Chest, 2006

41. Preoperative immunonutrition and immune function Braga et al. 2002

42. Nutritional supplementation during acute illnessin elderly patients randomized, double-blind, placebo-controlled trial Gariballa S et al. 2006

43. Frequency ofmalnutrition Cost of malnutrition

46. Malnutrition in Swedish hospitals

47. Stratton et al 2005

48. Empty fridge study Sieber et al 2002

49. Malnutrition increases mortality Stratton et al 2006

50. Malnutrition increases cost of care