Síndrome de enterocolitis inducida por la proteína de los alimentos (FPIES). Presentación de un caso clínico pediátrico / Food protein-induced enterocolitis syndrome (FPIES). A pediatric clinical case / Síndrome de enterocolite induzida por proteínas alimentares (FPIES). Relato do caso pediátrico

Resumen: Introducción: el síndrome de enterocolitis inducida por la proteína de los alimentos (FPIES) es un tipo de alergia alimentaria poco frecuente, no mediada por inmunoglobulinas E. Afecta principalmente a menores de 1 año. Es una entidad de diagnóstico clínico y el tratamiento se basa en la exclusión del alimento causal. El objetivo de esta comunicación es alertar sobre una patología poco habitual que requiere un alto índice de sospecha para el diagnóstico y abordaje adecuados. Caso clínico: niña, 5 meses, con antecedentes de dermatitis atópica, alimentada con pecho directo exclusivo, que dos horas luego de la introducción por primera vez de derivado de leche de vaca, en apirexia presenta vómitos reiterados, letargia y al examen físico hiporreactividad, frialdad periférica y tiempo de recoloración prolongado. Frecuencia cardíaca 145 cpm. Resto, sin alteraciones. Niega ingesta o contacto con fármacos o tóxicos. Se realiza fluidoterapia con suero fisiológico y oxigenoterapia con rápida mejoría. Permanece en observación en unidad de cuidado intensivo por 24 horas, con buena evolución. Se otorga alta con diagnóstico de episodio paroxístico de etiología no aclarada. En la evolución, a los diez días, tras la ingesta de otros alimentos, presenta episodio de similares características. En interconsulta con gastroenterólogo se realiza diagnóstico retrospectivo de FPIES y se indica dieta de exclusión. Conclusiones: dada la similitud de las manifestaciones clínicas de FPIES con otras enfermedades de mayor prevalencia, es importante que los pediatras conozcan esta entidad y puedan sospecharla para realizar un adecuado abordaje y evitar fundamentalmente la exposición futura al alimento desencadenante.

Summary: Introduction: the Food Protein- Induced Enterocolitis Syndrome (FPIES) is a rare type of food allergy, not mediated by immunoglobulins E. It mainly affects children below one year of age. Its diagnosis is clinical and treatment are based on the exclusion of the food that triggers it. The objective of this report is to warn about a rare pathology that requires awareness and suspicion in order to set a proper diagnosis and approach. Clinical case: 5 month-old girl, with a history of atopic dermatitis, exclusively breastfed, who, after the first introduction of a cow milk byproduct, presented vomit, lethargy, hyporeaction, and manifestations of peripheral circulatory failure, like cool distal extremities and delayed capillary refill. No fever. Heart rate 145. No further alterations. Denies ingestion or contact with drugs and/or toxic substances. We administered a rapid fluid bolus with sodium chloride and oxygen therapy and she improved rapidly. She stayed under observation in an intensive care unit for 24 hours and showed good evolution. The patient was discharged with a diagnosis of paroxysmal episode of unknown etiology. During the evolution, 10 days after the intake of other foods, she experienced an episode of similar characteristics. We consulted with a gastroenterologist, and diagnosed FPIES, and she was prescribed an exclusion diet. Conclusions: considering the similarity of FPIES clinical manifestations with those of other more prevalent diseases, it is important that pediatricians know about this condition and are able to suspect about it in order to devise a suitable approach, mainly to avoid future exposure to the food triggering the syndrome.

Resumo: Introdução: a síndrome de enterocolite induzida por proteínas alimentares (FPIES) é um tipo raro de alergia alimentar, não mediada por imunoglobulinas E. Afeta principalmente crianças menores de um ano. É uma entidade de diagnóstico clínico e o tratamento é baseado na exclusão do alimento causal. O objetivo deste paper é alertar sobre uma patologia incomum que requer um alto índice de suspeita para diagnóstico e abordagem adequados. Relato de caso: menina de 5 meses, com história de dermatite atópica, alimentada com mama direta exclusiva, que duas horas após a primeira introdução do derivado de leite de vaca, apresentou vômitos, letargia, hiporreatividade, manifestações de falha circulatória periférica como extremidades frias e tempo de recoloração prolongado. Frequência cardíaca 145 cpm. O resto sem alterações. Nega ingestão ou contato com drogas ou toxinas. A fluidoterapia é realizada com soro fisiológico e oxigenoterapia e a menina melhora rapidamente. Permanece em observação na unidade de terapia intensiva por 24 horas com boa evolução. A alta é dada com o diagnóstico de episódio paroxístico de etiologia pouco clara. Na evolução, 10 dias após a ingestão de outros alimentos, apresenta episódio de características semelhantes. Consultamos com o gastroenterologista, e realizamos um diagnóstico retrospectivo de FPIES e indicamos uma dieta de exclusão. Conclusões: dada a semelhança das manifestações clínicas do FPIES com outras doenças de maior prevalência, é importante que o pediatra conheça essa entidade e possa suspeitar e executar uma abordagem adequada e evitar fundamentalmente a exposição futura aos alimentos causales.

Meta, prescrição e infusão da terapia nutricional enteral de pacientes críticos em unidade de terapia intensiva / Target, prescription and infusion of enteral nutritional therapy of critical patients in intensive care unit

ABSTRACT BACKGROUND: Enteral nutritional therapy (ENT) is the best route for the nutrition of critically ill patients with improved impact on the clinical treatment of such patients. OBJECTIVE: To investigate the energy and protein supply of ENT in critically ill in-patients of an Intensive Care Unit (ICU). METHODS: Prospective longitudinal study conducted with 82 critically ill in-patients of an ICU, receiving ENT. Anthropometric variables, laboratory tests (albumin, CRP, CRP/albumin ratio), NUTRIC-score and Nutritional Risk Screening (NRS-2002), energy and protein goals, and the inadequacies and complications of ENT were assessed. Statistical analysis was performed using the Chi-square or Fischer tests and the Wilcoxon test. RESULTS: A total of 48.78% patients were at high nutritional risk based on NUTRIC score. In the CRP/albumin ratio, 85.37% patients presented with a high risk of complications. There was a statistically significant difference (P<0.0001) for all comparisons made between the target, prescription and ENT infusion, and 72% of the quantities prescribed for both calories and proteins was infused. It was observed that the difference between the prescription and the infusion was 14.63% (±10.81) for calories and 14.21% (±10.5) for proteins, with statistically significant difference (P<0.0001). In the relationship between prescription and infusion of calories and proteins, the only significant association was that of patients at high risk of CRP/albumin ratio, of which almost 94% received less than 80% of the energy and protein volume prescribed (P=0.0111). CONCLUSION: The administration of ENT in severely ill patients does not meet their actual energy and protein needs. The high occurrence of infusion inadequacies, compared to prescription and to the goals set can generate a negative nutritional balance.

RESUMO CONTEXTO: A terapia nutricional enteral (TNE) é a melhor via para a nutrição de pacientes críticos e com melhores impactos no tratamento clínico desses pacientes. OBJETIVO: Investigar a oferta energética e proteica da TNE em pacientes críticos, internados em uma unidade de terapia intensiva (UTI) de um hospital universitário. MÉTODOS: Um estudo prospectivo longitudinal foi conduzido com 82 pacientes críticos internados em uma UTI, recebendo TNE. Foram estudadas variáveis antropométricas, exames laboratoriais (albumina, PCR, relação PCR/albumina), NUTRIC-score e o Nutritional Risk Screening (NRS-2002), metas energéticas e proteicas e as inadequações e complicações da TNE. A análise estatística foi realizada utilizando-se os testes Qui-quadrado ou Fischer e o teste de Wilcoxon, com nível de significancia de P<0,05. RESULTADOS: Na avaliação pelo NUTRIC score, 48,78% apresentaram alto risco nutricional. Na relação PCR/albumina, 85,37% apresentaram alto risco de complicações. Verificou-se diferença estatisticamente significante (P<0,0001) para todas as comparações efetuadas entre a meta, prescrição e infusão da TNE, sendo infundido 72% do que foi prescrito tanto para caloria como para proteína. Observou-se que a diferença entre a prescrição e a infusão foi de 14,63% (±10,81) para caloria e de 14,21% (±10,5) para proteína, com diferença estatisticamente significante (P<0,0001). Na relação entre prescrição e infusão de calorias e proteínas, a única associação significativa foi a dos pacientes com alto risco para a relação PCR/albumina, destes; quase 94% receberam menos que 80% do volume energético e proteico prescrito (P=0,0111). CONCLUSÃO: A administração da TNE em pacientes graves, não supre suas reais necessidades energéticas e proteicas. A alta ocorrência de inadequações da infusão, comparadas à prescrição e às metas definidas podem gerar balanço nutricional negativo.

A New Phe-Free Protein Substitute Engineered to Allow a Physiological Absorption of Free Amino Acids for Phenylketonuria

Abstract An innovative technology (Physiomimic Technology) has been applied to amino acids (AAs) formulated for patients with phenylketonuria, with the objective of masking AA taste and odor and prolonging AA release in the gut, allowing a physiological absorption. This technology entails that the AAs are processed with functional additives that are able to modify their release and their organoleptic features. Two prototypes, obtained using sodium alginate + ethylcellulose (engP-1) or sodium alginate + ethylcellulose + glyceryl dibehenate (engP-2), have been tested for AA prolonged release versus the same AAs (n-engP) without the application of the Physiomimic Technology. In vitro tests indicated that the technology is able to prolong the release of the engineered AAs versus the free compounds. A crossover in vivo kinetic study in pigs showed reduced peak concentrations (Cmax) and, as expected, similar areas under the concentration/time curve (up to 5 hours) for the engineered products versus the free AAs. Significantly lower Cmax values (P < .01) were attained for essential AAs, large neutral AAs, and branched-chain AAs, indicating that the technology is able to reduce the typical absorption peak of free AAs. Taste and odor masking has been obtained as a consequence of the AA coating. The Physiomimic Technology, applied to free AAs, provided AA mixes with improved organoleptic features and with modified AA kinetics sustaining a more physiological AA absorption.

Factors associated with protein consumption in elderly / Fatores associados ao consumo proteico de idosos

ABSTRACT Objective We evaluated factors associated with protein consumption by the elderly. Methods We performed a cross-sectional study in a sample of 295 elderly consumers of health facilities in São Caetano do Sul, São Paulo, Brazil. Protein consumption data (g and g/kg) were obtained through 24-hour dietary recalls, which was reapplied in a 30% sub-sample to estimate habitual consumption, with an interval of two weeks. The association between protein consumption and sociodemographic, economic, health, and dietary variables was tested using multiple linear regression. Results There was a positive association between protein consumption (g and g/kg) and better Brazilian Healthy Eating Index-Revised, between protein consumption (g) and male sex, and a negative association between protein consumption (g/kg) and greater calf circumference. Higher average protein consumption (g or g/kg) was observed among married elderly, individuals with higher income and schooling, who were economically active, eutrophic, without dyslipidemia and symptoms of dysphagia, who consumed three main meals and an intermediate snack. Conclusion The results showed that protein consumption was associated with diet quality, sex, and calf circumference. The identification of elderly groups prone to protein inadequacy may direct individual and collective interventions to prevent muscle mass reduction and its implications, such as sarcopenia and other adverse outcomes.

RESUMO Objetivo Avaliar os fatores associados ao consumo proteico de idosos. Métodos Estudo transversal descritivo realizado com 295 idosos usuários de centros para terceira idade e unidades de saúde do Município de São Caetano do Sul, São Paulo. O consumo proteico (g e g/kg) foi obtido na avaliação do recordatório de 24 horas, que foi reaplicado numa subamostra de 30% para estimar o consumo habitual, com intervalo máximo de duas semanas. A associação entre proteína e variáveis sociodemográficas, econômica, de saúde e dietéticas foram testadas por meio de regressão linear múltipla. Resultados Houve associação positiva entre o consumo de proteína (g e g/kg) e melhor Índice de Qualidade da Dieta Revisado, entre o consumo de proteína (g) com o sexo masculino, e associação negativa entre proteína (g/kg) e maior circunferência da panturrilha. Maior consumo médio de proteína (g e/ou g/kg) foi observado entre idosos casados, com maior renda e escolaridade, economicamente ativos, eutróficos, sem dislipidemia e sintomas de disfagia, que consumiram as três refeições principais e lanche intermediário. Conclusão Os resultados demonstraram que o consumo proteico foi associado à qualidade da dieta, sexo e circunferência da panturrilha. A identificação de grupos de idosos propensos à inadequação proteica pode direcionar intervenções individuais e coletivas com intuito de prevenir a redução de massa muscular e suas implicações, como sarcopenia e outros desfechos adversos.

Un caso inusual de síndrome de enterocolitis inducida por proteínas alimentarias / Unusual case of food protein-induced enterocolitis syndrome

El síndrome de enterocolitis inducido por proteínas alimentarias es un síndrome de hipersensibilidad gastrointestinal a alimentos no mediado por inmunoglobulina E, que, en su forma aguda, se manifiesta con vómitos repetitivos, palidez e hipotonía, que puede acompañarse o no de diarrea y producir un cuadro grave de deshidratación y letargia. Una prueba de provocación oral controlada es, en ocasiones, realizada para confirmar el diagnóstico y el tratamiento consiste en la eliminación del alimento causante. Se presenta el caso de un lactante de 3 meses con varios episodios de síndrome de enterocolitis tras la toma de biberón de leche de fórmula de inicio con tolerancia de otra marca comercial. Se encontraron diferencias en los ingredientes de su composición que podrían ser el origen de la sensibilización.

Food protein-induced enterocolitis syndrome is a nonimmunoglobulin E mediated gastrointestinal food hypersensitivity that manifests as profuse, repetitive vomiting, pallor and hypotonia, often with diarrhea leading to severe dehydration and lethargy (sepsis-like symptoms) in the acute setting. An oral food challenge is sometimes performed to confirm the diagnosis and treatment consists of elimination of the food trigger(s) from the diet. We report a case of a 3-months-old infant with several episodes of food protein-induced enterocolitis syndrome after taking infant formula milk with tolerance of another trademark. Differences in the composition of its ingredients could be the cause of the sensitization.

Qualidade da dieta de estudantes de uma universidade pública brasileira / Diet quality of students at a brazilian public university

O objetivo deste estudo transversal foi avaliar as dietas de acadêmicos de uma universidade pública brasileira quanto à adequação energética, ao consumo de macro e micronutrientes e de fibras alimentares. A pesquisa foi realizada de março/2010 a dezembro/2011, utilizando-se o Registro Alimentar de três dias e o software Dietpro5i para a coleta e a determinação da composição das dietas, respectivamente. O estudo envolveu 278 indivíduos distribuídos em quatro grupos: Educação Física/feminino (n=66), Educação Física/masculino (n=69), Farmácia/feminino (n=79) e Farmácia/masculino (n=64). Realizou-se estatística descritiva e ANOVA/post hoc de Tukey (SPSS vs.14.0). Em todos os grupos, observou-se uma dieta hiperenergética, hiperproteica, hiperglicídica, adequada quanto à contribuição calórica dos macronutrientes e em ferro e deficiente em cálcio e fibras alimentares. Observou-se que 39,3% de todos os indivíduos apresentaram consumo insuficiente de zinco. Comparando estatisticamente os grupos, destaca-se que o maior consumo energético médio pertence ao grupo Educação Física/masculino (3.760,3±686,6 kcal/dia; p<0,002 para todos os grupos), sendo que 53,1% deles realizavam uma dieta hipercalórica. Esse grupo também apresentou o maior consumo médio de proteínas (1,7±0,7 g/kg/dia), carboidratos (358,8±91,4 g/dia), ferro (13,9±4,5 mg/dia) (p<0,05 para esses componentes de todos os grupos) e zinco (12,1±5,3 mg/dia; p=0,004 para Farmácia/masculino). Do grupo Farmácia/feminino, observou-se o menor consumo médio de cálcio (601,1±227,0 mg/dia; p<0,022 para homens de ambos os cursos), enquanto o grupo Farmácia/masculino apresentou o maior percentual de indivíduos com dieta deficiente em fibras alimentares (85,8%; p=0,022 para Farmácia/feminino). Essas constatações sinalizam algumas inadequações alimentares, as quais podem constituir um fator de risco, a longo prazo, para a saúde dessa população.

The aim of this study was to evaluate students' diets at a Brazilian public university with regard to energetic adequacy and the consumption of macronutrients, micronutrients, and dietary fiber. This research was conducted from March/2010 to December/2011, using the Three-day Diet Record and Dietpro5i software, to collect and analyze the diet composition information. It was composed of 278 subjects, divided into four groups: Physical Education/ female (n=66), Physical Education/male (n=69), Pharmacy/female (n=79), and Pharmacy/male (n=64). Descriptive statistics and ANOVA/post hoc Tukey were performed (SPSS vs.14.0). All groups presented diets with high contents in energy, carbohydrates, and protein; adequate for macronutrient caloric contribution and iron; and low in calcium and dietary fiber. It was observed that 39.3% of all individuals presented low zinc consumption. Statistically comparing the groups, what stands out is that the highest mean energy consumption was found in the Physical Education/male group (3.760.3±686.6 kcal/ day; p<0.002 among all groups), and 53.1% of them were under a high-energy diet. This group also presented the highest mean consumption for protein (1.7±0.7 g/kg/ day), carbohydrates (358.8±91.4 g/day), iron (13.9±4.5 mg/day) (p<0.05 for this component among all groups), and zinc (12.1±5.3 mg/day; p=0.004 for Pharmacy/male). Pharmacy/female presented the lowest mean calcium consumption (601.1±227.0 mg/day; p<0.022 for both male groups), while the Pharmacy/male group presented the highest percentage of individuals with deficient dietary fiber intake (85.8%; p=0.022 for Pharmacy/ female). Some results indicate dietary inadequacy, which can become a risk factor for this population's health in the long term.

Supplementation of an Orange Juice with Dietary Proteins to Prevent Enamel and Dentin Erosion

Protein supplementation may be an alternative to reduce the erosive potential of acidic drinks. The aim of this in vitro study was to evaluate the erosive potential of an orange juice modified by dietary proteins. A commercially available orange juice was added 0.2 g/L casein, 2.0 g/L ovalbumin and their combination. The juice with no additives and a commercially available calcium-modified juice were used as negative and positive controls, respectively. Human enamel and dentin specimens (n=11) were tested in an erosion-remineralization cycling model. Enamel was analyzed by surface microhardness and profilometry, whilst dentin by profilometry only. Statistical analyses were performed using one-way ANOVA followed by Tukey's test (p<0.05). Calcium-modified juice showed the lowest erosive potential for both analyses (p<0.05). For enamel, the protein-added groups did not differ from each other (p>0.05) and showed significantly lower enamel loss compared to negative control (p<0.05). Regarding surface microhardness, casein showed the highest values compared to negative control (p<0.05). For dentin, none of the protein-added groups showed lower values of surface loss compared to negative control (p>0.05). In conclusion, for enamel the protein-modified orange juices presented reduced erosion of enamel, with casein showing a trend for better protection. For dentin, no reduction in the erosive potential was observed for the tested protein-modified orange juices.

A suplementação de proteína pode ser uma alternativa na redução do potencial erosivo de bebidas ácidas. O objetivo deste estudo in vitro foi avaliar o potencial erosivo do suco de laranja modificado por proteínas da dieta. A um suco de laranja disponível comercialmente foi adicionado 0,2 g/L de caseína, 2,0 g/L de ovalbumina e suas combinações. O suco sem aditivos, e um suco suplementado com cálcio foram utilizados como controles negativos e positivos, respectivamente. Espécimes de esmalte humano e de dentina radicular (n=11) foram testados em um modelo de ciclagem de erosão-remineralização. O esmalte foi analisado por microdureza de superfície e perfilometria, enquanto que a dentina, apenas por perfilometria. As análises estatísticas foram realizadas utilizando ANOVA um fator seguido pelo Teste de Tukey (p<0.05). O suco suplementado com cálcio mostrou o menor potencial erosivo para ambas as análises (p<0,05). Em relação ao esmalte, os grupos com adição de proteína não diferiram entre si (p>0,05) e mostraram significativamente uma menor perda de esmalte em relação ao grupo controle negativo (p<0,05). Para a microdureza, a caseína apresentou os maiores valores em relação ao controle negativo (p<0,05). Para a dentina, nenhum dos grupos com adição de proteína apresentou valores de perda de superfície menores quando comparados ao grupo controle negativo (p>0,05). Conclui-se que, para o esmalte os sucos de laranja modificados por proteínas apresentaram uma redução da erosão, com a caseína mostrando uma tendência para melhor proteção. Para a dentina, nenhuma redução da erosão foi observada para os sucos de laranja modificados por proteínas testados neste estudo.

Alcohol, Smoking, Physical Activity, Protein, and Lower Urinary Tract Symptoms: Prospective Longitudinal Cohort / 대한배뇨장애요실금학회지

PURPOSE: To evaluate risk factors for deterioration of lower urinary tract symptoms (LUTS) in elderly men in a community-based, prospective longitudinal cohort study. METHODS: In a suburban area in Korea, 1,514 subjects aged > or =45 years were randomly selected by systematic sampling. A total of 918 elderly subjects were enrolled in this in-depth clinical study in 2004. Of these, 547 participants were followed up for 3 years and the data was analyzed in 2014. Standard questionnaires were administered face-to-face by trained interviewers. After excluding women, 224 male participants with complete data including transrectal ultrasonography were included in the final analysis. LUTS were diagnosed using the International Prostate Symptom Score (IPSS) questionnaire. Symptom deterioration was defined as a score of > or =8 points during the 3-year follow-up period. RESULTS: LUTS prevalence increased to 13.1% and the mean IPSS increased by 2.6 points during the 3-year period. After adjusting for confounders, a smoking history of > or =50 pack-years was an independent risk factor for deterioration of LUTS and storage subsymptoms compared with no history of smoking (3.1 and 5.1 odds, respectively). Physical activity had a protective effect on voiding subsymptoms. However, high protein diet and alcohol intake were not associated with LUTS deterioration. CONCLUSIONS: The LUTS prevalence among elderly men living in a suburban area increased to 13.1% and the IPSS increased by 2.6 points during the 3-year period. A history of heavy smoking, low physical activity, and high protein intake were associated with LUTS deterioration. However, there was no significant association between alcohol intake and LUTS deterioration.

Food Protein-Induced Enterocolitis Syndrome in a Neonate with Peripheral Epimerase Deficiency Galactosemia

Food protein-induced enterocolitis syndrome (FPIES) is a severe infantile form of non-immunoglobulin E-mediated gastrointestinal food hypersensitivity that manifests as profuse, repetitive vomiting, often with diarrhea, which leads to acute dehydration and lethargy and failure to thrive if chronic. Symptoms such as dehydration and lethargy are also observed in sepsis, viral infection, and food poisoning. It is difficult to differentiate FPIES from sepsis-like illness. The diagnosis is based on clinical criteria and/or an oral food challenge. FPIES developed in the patient with peripheral epimerase deficiency galactosemia after the use of soy formula. The change in feeding to soy formula is not required of a patient with peripheral epimerase deficiency galactosemia. Early intake of soy formula in our patient was harmful. Therefore, we think the changing the formula should be taken carefully. Another important point is the diagnosis. Late diagnosis and misdiagnosis are common, and inappropriate treatment or invasive treatment can occur.

Ingestão proteica na encefalopatia hepática: panorama atual / Protein intake in hepatic encephalopathy: current concepts

Hepatic encephalopathy is a severe complication of cirrhosis and comprises a complexand multifactorial pathophysiology. However, ammonia exchange between different tissues still deserves attention in relation to neurological alterations. Hepatic encephalopathy treatment remains focused on the trigger factor correction and the ammonia formation. Therefore, it was believed that high-proteic diets could lead to hepatic encephalopathy through the accumulation of nitrogen compounds in the gastrointestinal tract, which could increase production and absorption of ammonia.Currently, it is known that proteic restriction is harmful to cirrhotic patients, but it isstill utilized. Malnutrition is highly prevalent among cirrhotic individuals with hepatic encephalopathy, thus indicating a nutritional risk which is clearly related to higher mortality rates. Furthermore, there is an increase in the protein needs of these patients and also a relationship between the loss of lean mass and hyperammonaemia. For these and other factors herein discussed, today's global guidelines recommend the ingestion of higher protein levels for patients with hepatic encephalopathy

A encefalopatia hepática é uma complicação grave da cirrose e envolve uma fisiopatologia complexa e multifatorial. Entretanto, a influência da amônia nos diferentes tecidos ainda merece atenção no que se refere às manifestações neuropatológicas. O tratamento da encefalopatia hepática permanece focado na correção do distúrbio desencadeante e na diminuição da formação da amônia a partir do cólon. Por conta disso, acreditava-se que dietas ricas em proteínas poderiam desencadear a encefalopatia hepática por meio do aporte de nitrogênio no trato gastrointestinal, podendo aumentar a produção e a absorção da amônia. Atualmente, sabe-se que a restrição proteica é prejudicial para portadores de cirrose, embora ainda utilizada. A desnutrição é prevalente entre indivíduos cirróticos com encefalopatia hepática, indicando um estado nutricional de risco que está nitidamente relacionado às maiores taxas de mortalidade. Além disso, há um aumento nas necessidades proteicas desses pacientes e uma relação entre a perda de massa magra e a hiperamoniemia. Com base em tais fatores, os guidelines atuais mundiais recomendam dieta hiperproteica para pacientes com encefalopatia hepática.

Necessidades proteicas, morbidade e mortalidade no paciente grave: fundamentos e atualidades / Protein requirements, morbidity and mortality in critically ill patients: fundamentals and applications

Evidências recentes sugerem que o balanço proteico negativo secundário à doença grave se associa ao aumento de morbidade. A perda da proteína corporal total é inevitável nesse cenário, mesmo com uma abordagem nutricional agressiva, e resulta, principalmente, do catabolismo da fibra muscular esquelética. O principal mecanismo bioquímico e metabólico envolvido nesse processo é o sistema ubiquitina-proteassoma, que, paradoxalmente, consome a adenosina trifosfatocomo fonte energética e motriz. É possível que a neutralidade do balanço proteico nessas instâncias clínicas, seja tão importante na melhora dos desfechos quanto atingir a meta calórica estimada ou medida pela calorimetria indireta. Estudos recentes apontam a utilização de concentrações mais elevadas de proteínas na terapia nutricional do paciente grave como importante para um impacto positivo na mortalidade. A proposta deste trabalho foi revisar alguns princípios da terapia nutricional relativos ao metabolismo proteico, sinalizar para as principais assertivas das diretrizes das sociedades especializadas e comentar estudos recentes, que abordam a questão em tela, sob a visão crítica da experiência clínica dos autores.

Recent evidence suggests that a negative protein balance secondary to severe disease is associated with increased morbidity. A loss of total body protein is inevitable in this scenario, even with an aggressive nutritional approach, primarily due to the catabolism of skeletal muscle fibers. The ubiquitin-proteasome system is the primary metabolic and biochemical mechanism involved in this process; paradoxically, this system consumes adenosine triphosphate as its energy source. It is possible that a neutral protein balance in these clinical situations is important for improving outcomes and achieving the caloric goals estimated or measured by indirect calorimetry. Recent studies have suggested that the use of higher protein concentrations in nutritional therapy for critically ill patients may help to reduce mortality. The purpose of this study was to review some of the nutrition therapy principles related to protein metabolism, evaluate the main assertions of the guidelines of specialty societies and review the recent studies that address these issues using critical insights from the authors' clinical experience.

Consumo de macronutrientes e ingestão inadequada de micronutrientes em adultos / Macronutrient consumption and inadequate micronutrient intake in adults / Consumo de macronutrientes e ingestión inadecuada de micronutrientes en adultos

OBJETIVO: Estimar o consumo de energia e nutrientes e a prevalência de ingestão inadequada de micronutrientes entre adultos brasileiros. MÉTODOS: Foram analisados dados do Inquérito Nacional de Alimentação da Pesquisa de Orçamento Familiar 2008-2009. O consumo alimentar foi avaliado por dois dias de registro alimentar não consecutivos. Um total de 21.003 indivíduos (52,5% mulheres) entre 20 e 59 anos de idade participou do estudo. A ingestão usual de nutrientes foi estimada pelo método proposto pelo National Cancer Institute. As prevalências de ingestão inadequada de micronutrientes foram obtidas pelo método da necessidade média estimada (EAR) como ponto de corte. Para manganês e potássio, a Ingestão Adequada (AI) foi usada como ponto de corte. A ingestão de sódio foi comparada com o nível de ingestão máximo tolerável (UL). A prevalência de inadequação da ingestão de ferro foi determinada por abordagem probabilística. Os dados foram analisados de acordo com a localização do domicílio (área urbana ou rural) e as macrorregiões do país. RESULTADOS: A média do consumo energético foi de 2.083 kcal entre os homens e 1.698 kcal entre as mulheres. Prevalências de inadequação maiores ou iguais a 70% foram observadas para cálcio entre os homens e magnésio, vitamina A, sódio em ambos os sexos. Prevalências maiores ou iguais a 90% foram encontradas para cálcio entre as mulheres e vitaminas D e E em ambos os sexos. Prevalências menores que 5% foram encontradas para ferro entre os homens e niacina para homens e mulheres. No geral, a prevalência de ingestão inadequada foi mais acentuada na área rural e na região Nordeste. CONCLUSÕES: O consumo de energia é maior entre indivíduos residentes em áreas urbanas e da região Norte. Os grupos com maior risco de ingestão inadequada de micronutrientes são as mulheres e os que residem na área rural e na região Nordeste.

OBJECTIVE: To estimate energy and nutrient intake and prevalence of inadequate micronutrient intake among Brazilian adults. METHODS: Data from the National Dietary Survey, from the 2008-2009 Household Budget Survey, were used. Food consumption was evaluated through food record on two non-consecutive days. A total of 21,003 individuals (52.5% women), between 20-59 years old, participated in the survey. Usual nutrient intake was estimated according to the National Cancer Institute method. The Estimated Average Requirement (EAR) cut-off points were used to determine the prevalence of inadequate micronutrient intake. For manganese and potassium, the Adequate Intake (AI) was used as cut-off. Sodium intake was compared with the Tolerable Upper Intake Level (UL). The probability approach was used to determine the prevalence of inadequate iron intake. The data were analyzed according to the location of the household (urban or rural) and macro regions of Brazil. RESULTS: The mean energy intake was 2,083 kcal among men and 1,698 kcal among women. Prevalence of inadequacy equal to or greater than 70% were observed for calcium among men and magnesium, vitamin A, and sodium among both men and women. Prevalence equal to or greater than 90% were found for calcium in women and vitamins D and E in both genders. Prevalence lower than 5% were found for iron in men and for niacin in men and women. In general, prevalence of inadequate intake was higher in the rural area and in the Northeast region. CONCLUSIONS: Energy intake was higher among individuals who live in urban areas and in the North region. The greatest risk groups of inadequate micronutrient intake were women and those living in rural areas and in the Northeast region.

OBJETIVO: Estimar el consumo de energía y nutrientes y la prevalencia de ingestión inadecuada de micronutrientes entre adultos brasileños. MÉTODOS: Se analizaron datos de la Pesquisa Nacional de Alimentación de la Investigación de Presupuesto Familiar 2008-2009. El consumo de alimentos fue evaluado por dos días no consecutivos de registro alimenticio. Un total de 21.003 individuos (52,5% mujeres) entre 20 y 59 años de edad participó del estudio. La ingesta usual de nutrientes fue estimada por el método propuesto por el National Cancer Institute. Las prevalencias de ingestión inadecuada de micronutrientes fueron obtenidas por el método de la necesidad promedio estimada (EAR) como punto de corte. Para manganeso y potasio, la Ingestión Adecuada (IA) fue usada como punto de corte. La ingestión de sodio fue comparada con el nivel de ingestión máxima tolerable (UL). La prevalencia de ingestión inadecuada de hierro fue determinada por abordaje probabilístico. RESULTADOS: El promedio de consumo energético fue de 2.083 kcal entre los hombres y 1698 kcal entre las mujeres. Prevalencias de ingesta inadecuada mayores o iguales a 70% fueron observadas para calcio entre los hombre y magnesio, vitamina A, sodio en ambos sexos. Prevalencias mayores o iguales a 90% fueron encontradas para calcio entre las mujeres y vitaminas D y E en ambos sexos. Prevalencias menores que 5% fueron encontradas para hierro entre los hombres y niacina para hombres y mujeres. En general, la prevalencia de ingesta inadecuada fue más acentuada en el área rural y en la región Noreste. CONCLUSIONES: El consumo de energía es mayor entre individuos residentes en áreas urbanas y de la región norte. Los grupos con mayor riesgo de ingestión inadecuada de micronutrientes son las mujeres y los que residen en el área rural y en la región Noreste.

Carga ácida potencial renal de la dieta en niños de 2 a 6 años / Potential renal acid load in children from 2 to 6 years of age

El consumo proteico excesivo incrementa la producción endógena de ácido, lo que puede conducir a acidosis metabólica, pérdida de masa ósea, hipercalciuria, urolitiasis, retardo del crecimiento y sarcopenia, entre otros. Estimar y analizar la Carga Ácida Potencial Renal (CAPR) de la dieta en niños de 2 a 6 años. Estudio descriptivo y transversal, que incluyó 52 niños de la consulta de niños sanos del Instituto de Previsión y Asistencia Social del Ministerio del Poder Popular para la Educación, estado Miranda. Las principales variables estudiadas fueron: (1) consumo de macronutrientes, y patrón alimentario evaluado mediante recordatorio de 24 horas (R24h) y cuestionario de frecuencia de consumo (CFC). El R24H permitió determinar adecuación nutricional y el CFC la calidad de la dieta y factores de protección y riesgo dietético para una mayor carga ácida de la dieta. El consumo de nutrientes se comparó con recomendaciones nacionales e internacionales; (2) la CAPR según el método de Remer y Manz. Para el análisis estadístico se utilizó el programa SPSS, v17.0. El consumo de proteínas estuvo elevado en 46,15% de los niños. Los alimentos con mayor desbalance fueron: carnes y lácteos por consumo excesivo, frutas y hortalizas por consumo deficiente. La CAPR fue positiva en 96,2% de los niños y se correlacionó positivamente (p<0,05) con el consumo de energía, proteínas, grasas, carnes y lácteos. La dieta de los niños estudiados se caracterizó por su excesiva carga ácida con el consecuente riesgo para la generación de ácidosis sistémica y sus consecuencias metabólicas

High protein intake increases endogenous acid production, which may lead to metabolic acidosis, decrease in bone and muscle mass, hipercalciuria and urolithiasis, among other disorders. Estimate and analyze the Potential Renal Acid Load (PRAL) of the diet in children from two to six years of age. The study is descriptive, cross-sectional and correlational wich included fifty two children who assisted to an ambulatory well child clinic in Carrizales, Miranda State, Venezuela. The main variables studied were: (1) Macronutrient food intake and diet pattern which was assessed by a 24 hour recall (24hR) and a food frequency questionnaire (FFQ). The 24hR allowed to evaluate nutritional adequacy and the FFQ, the diet quality, as well as diet protection and risk factors. Nutrient intake was compared with national and international recommendations; (2) PRAL was determined according to Remer and Manz. Statistical analysis was performed by means of the SPSS, v17.0 software. Protein intake was high in 46,15% of the children. Food groups with the highest unbalance were meat and dairy products for excessive intake and fruits and vegetables for defective intake, both of which represent risk factors for acid production. PRAL was positive in 92% of the children and was positively correlated (p<0.05) with intake of energy, proteins, fat and with the food groups of meat and dairy. The diet of the studied children was characterized by an excessive acid load with the risk for the generation of systemic acidosis and its metabolic consequences

Asociación entre el consumo de macronutrientes de la dieta y caries en adultos y adultos mayores diabéticos tipo 2 / Association between dietary macronutrients and caries in type 2 diabetic adults and elderly

Objetivos: Se ha reportado una mayor tasa de caries en pacientes con diabetes mellitus tipo 2 (DM), probablemente debido a cambios en los patrones de dieta. El objetivo de este estudio fue determinar si existe una asociación entre la composición de macronutrientes de la dieta y la caries en sujetos con DM. Métodos: Una muestra compuesta por 33 sujetos con DM y 37 controles sin la patología fue examinada para determinar la experiencia de caries mediante el índice COPD y la prevalencia de caries radiculares con ICDAS II. Se aplicó una encuesta de dieta de reporte de 24 horas. Para determinar la composición de la dieta, los alimentos fueron clasificados acorde al contenido de macronutrientes; carbohidratos, proteínas y lípidos (gramos/día, kilocalorías y porcentaje del nutriente/día). Resultados: Los resultados fueron analizados mediante Kruskal-Wallis y Mann-Whitney. Un análisis de correlación y un modelo de regresión lineal se utilizaron para analizar la asociación entre composición de macronutrientes y la tasa de caries coronales y radiculares, con un nivel de significancia del 95 por ciento. Resultados: Los pacientes diabéticos tipo 2 mostraron mayor número de dientes perdidos por caries, más dientes obturados y más caries radiculares (p<0.05) que los controles sin DM. Los diabéticos presentaron menor consumo de carbohidratos (p=0.021), pero mayor consumo de proteínas (p=0.0405) que los controles. Se verificó una asociación directa entre un mayor consumo de proteínas con una tasa mayor de caries radiculares en pacientes con DM (p<0.001). Conclusión: Las diferencias en el consumo de macronutrientes en pacientes con DM no se relacionan con tasas diferenciales de caries coronales, pero un mayor consumo de proteínas se asocia con una mayor prevalencia de caries radiculares.

Objectives: Higher caries rates have been reported for type 2 diabetes mellitus patients (DM). Changes in dietary patterns may be partly responsible. The aim of this study was to examine a potential association between dietary macronutrient composition and caries experience in DM patients. Methods: Thirty three adults with DM and thirty seven controls, not affected by DM, were examined to assess coronal caries through DMFT index and root caries by ICDAS II. A 24-hr diet recall survey was used to determine dietary macronutrient composition supplemented with standardized tables and expressed as grams /day, kilocalories/nutrient and percentage of nutrient/day. Results were compared using Kruskal-Wallis and Mann-Whitney. A correlation analysis was performed and a linear regression model was built for a potential association between macronutrient composition and coronal or root caries. A 95 percent significance level was set. Results: DM patients showed lower remaining teeth, more fillings and more root caries (p<0.05) than controls. Lower carbohydrate consumption (p=0.021), but higher protein intake (p=0.0405) was observed in DM patients as compared with controls. A statistically significant association between an increased protein consumption and higher percentage of root caries was found in DM patients (p<0.001). Conclusion: Although differences in macronutrient consumption in DM patients are not correlated with differential rates of coronal caries, higher protein consumption appears to be associated with higher prevalence of root caries.

Dieta rica em proteína na redução do peso corporal / High-protein diet for body weight loss

A proporção ideal dos macronutrientes em dietas de emagrecimento é atualmente bastante discutida. Existem evidências de que dietas com maior proporção de proteína aumentam a perda de peso e de gordura corporal e diminuem a perda de massa corporal magra durante o emagrecimento. Todavia, os mecanismos responsáveis por estes efeitos não estão totalmente esclarecidos. Além disso, existem poucas conclusões a respeito dos possíveis efeitos colaterais dessas dietas na função renal e no estado nutricional relativo ao cálcio. Assim, este artigo objetiva trazer informações atuais sobre os efeitos de dietas ricas em proteína na perda de peso e na composição corporal e dos mecanismos envolvidos, bem como seus efeitos na função renal e no estado nutricional relativo ao cálcio.

The ideal proportion of macronutrients in weight loss diets is currently under debate. There are evidences indicating that a higher proportion of protein during weight loss diets enhances the loss of body weight and fat mass, and reduces the loss of lean body mass. Nevertheless, the responsible mechanisms for these effects have not yet been fully elucidated. Furthermore, studies that evaluated the possible side effects of these diets on the renal function and on the nutritional state of calcium have shown inconclusive results. Therefore, this article has the objective to convey recent information about the effects of high-protein diets in the regulation of the body weight and body composition, besides its involved mechanisms, and its effects on the renal function and on the calcium nutritional status.

Determinación de los índices glicémicos y de insulina en fórmulas para alimentación enteral en adultos sanos / Glycemic and insulin indices of tube feeding formulas in healthy adults

Background: In acute illnesses, plasma glucose levels are often increased and generally parallel the severity of stress. Hyperglycemia caused by reduced insulin sensitivity and reduced insulin secretion is associated with increased susceptibility to infections. Maintaining blood glucose levels at or below 110 mg/dl reduces morbidity and mortality in critically ill patients. Aim: To measure the glucose and insulin responses of four commercially available enteral formulas compared with a standard meal reference product. Material and Methods: The glycemic index (GI) and the insulin index (II) were determined in a randomized, cross over protocol in 38 healthy volunteers between 18 and 46 years of age. Each subject underwent five tests: three with the standard meal (bread) and two with the study products. The enteral formulas were Clinutren HPR (whole protein of high protein value), Crucial® (casein peptide based formula), Peptamen®, (whey peptide based formula), Glytrol® (formula for diabetics with whole protein with fiber). Each study product was evaluated 10 times. Results: The diabetic formula and the high protein energy dense formulas induced a significantly lower GI (p <0.02) compared with the standard meal. The GI response did not appear to be due to enhanced insulin secretion. The other tested formulas had lower GI than the standard meal, but in addition they exhibited increased II The whey based peptide formulation produced the highest insulin response (p <0.03). Conclusions: Both GI and II are related to the concentration, form and type of protein contained in the enteral formula. The whey peptide formulation produced a low GI with the highest insulin index. Based on the low GI of these enteral products, all can be useful to provide nutritional support during metabolic stress, without adding an additional challenge to blood glucose management.

Efecto de 2 dietas sobre aspectos biológicos de Blattella germanica (Dictyoptera: Blattellidae) en condiciones de laboratorio

Se realizó un estudio con 2 colonias de Blattella germanica (Dictyoptera:Blattellidae), mantenidas desde 1994 en el laboratorio a 29± 1ºC, 70-75 % de humedad relativa y con alimentos diferentes: una con una dieta carente de proteínas, consistente en porciones de papa (Solanum tuberosum, L.), plátano maduro (Musa paradisiaca, L.) y solución azucarada al 10 %, y la otra con un contenido preoteico de 20,45 % que consistió en alimento de laboratorio para rata, pulverizado y seco, y una fuente de agua. Se encontraron 6 estadios ninfales con ambos tipos de alimentos y se determinaron, en cada caso, los tiempos intermudas y el tiempo de desarrollo ninfal, éstos resultaron mucho más cortos en las ninfas alimentadas con proteínas. La longevidad de cada sexo no mostró diferencias significativas en relación con el tipo de alimento utilizado. Se determinaron los tiempos en que aparecen y eclosionan las ootecas de cada ciclo ootecal con ambos alimentos. Se encontró que las hembras depositaron hasta 5 ootecas durante su vida con los 2 tipos de dietas, el promedio de ninfas por ooteca en las hembras alimentadas con proteínas fue mucho mayor (t=5,33; p<=0,001). Los resultados de este estudio demuestran que cuando el alimento de B. germanica contiene proteínas, su desarrollo ninfal es más rápido y aumenta su capacidad reproductiva, lo que lo hace un nutriente necesario en la dieta de esta especie.

It was conducted a study of 2 colonies of Blattella germanica (Dictyoptera: Blattellidae) kept since 1994 in he laboratory at 29 ± 1º C, 70-75 % of relative humidity and with different foods: one on a diet without proteins, consisitging in portions of potatoes (Solanum tuberosum, L.), ripe banana (Musa paradisiaca, L.) and a sugary solution 10 %, and the other with a protein content of 20.45 % composed of pulverized and dry laboratory food for rats and a source of water. 6 nymphal stages were found with both types of food. There were determined the times of interchanges and the time of nymphal development, which were much shorter among the nymphs feeded with proteins. The longevity of each sex showed no significant differences in connection with the type of food used. The times of appearance and eclosion of the oothecae of each oothecal cycle were determined with both foods. It was found that the females deposited up to 5 oothecae during their lives with the 2 types of diet. The average of nymphs per ootheca among the females feeded with proteins was much greater (t= 5,33; p < 0,001). The results of this study show that when the food for B. germanica contains proteins, its nymphal development is faster and its reproductive capacity increases, which means that protein is a necessary nutrient for the diet of this species.