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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
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
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
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
Empty fridge study Sieber et al 2002
Malnutrition increases mortality Stratton et al 2006