Efficacy of Nutritional Intervention in Elderly After Hip Fracture: A Multicenter Randomized Controlled Trial.

Background: Malnutrition after hip fracture is associated with increased rehabilitation time, complications, and mortality. We assessed the effect of intensive 3 month nutritional intervention in elderly after hip fracture on length of stay (LOS). Methods: Open-label, randomized controlled trial. Exclusion criteria: age < 55 years, bone disease, life expectancy < 1 year, bedridden, using oral nutritional supplements (ONS) before hospitalization, and cognitive impairment. Intervention: weekly dietetic consultation, energy-protein-enriched diet, and ONS (400 mL per day) for 3 months. Control: usual nutritional care. Primary outcome: total LOS in hospital and rehabilitation clinic, including readmissions over 6 months (Cox regression adjusted for confounders); hazard ratio (HR) < 1.0 reflects longer LOS in the intervention group. Secondary outcomes: nutritional and functional status, cognition, quality of life, postoperative complications (6 months); subsequent fractures and all-cause mortality (1 and 5 years). Effect modification by baseline nutritional status was also tested. Results: One hundred fifty-two patients were randomized (73 intervention, 79 control). Median total LOS was 34.0 days (range 4-185 days) in the intervention group versus control 35.5 days (3-183 days; plogrank = .80; adjusted hazard ratio (adjHR): 0.98; 95% CI: 0.68-1.41). Hospital LOS: 12.0 days (4-56 days) versus 11.0 days (3-115 days; p = .19; adjHR: 0.75; 95% CI: 0.53-1.06) and LOS in rehabilitation clinics: 19.5 days (0-174 days) versus 18.5 days (0-168 days; p = .82; adjHR: 1.04; 95% CI: 0.73-1.48). The intervention improved nutritional intake/status at 3, but not at 6 months, and did not affect any other outcome. No difference in intervention effect between malnourished and well-nourished patients was found. Conclusions: Intensive nutritional intervention after hip fracture improved nutritional intake and status, but not LOS or clinical outcomes. Paradigms underlying nutritional intervention in elderly after hip fracture may have to be reconsidered.

Sedentary Behavior Is Only Marginally Associated with Physical Function in Adults Aged 40-75 Years-the Maastricht Study.

Background: In an aging population, regular physical activity (PA) and exercise have been recognized as important factors in maintaining physical function and thereby preventing loss of independence and disability. However, (older) adults spent the majority of their day sedentary and therefore insight into the consequences of sedentary behavior on physical function, independent of PA, is warranted. Objective: To examine the associations of objectively measured sedentary time (ST), patterns of sedentary behavior, overall PA, and higher intensity PA (HPA) with objective measures of physical function. Methods: This is a cross-sectional study in 1,932 men and women (aged 40-75 years) participating in The Maastricht Study. The activPAL3 was used to assess daily sedentary behavior: ST (h), sedentary breaks (n), prolonged (≥30 min) sedentary bouts (n), and to assess time spent in (H)PA (h). Measures of physical function included: covered distance during a 6 min walk test [6MWD (meters)], timed chair rise stand test performance [TCSTtime (seconds)], grip strength (kg kg-1), and elbow flexion and knee extension strength (Nm kg-1). Linear regression analyses were used to examine associations between daily sedentary behavior and PA with physical function. Results: Every additional hour ST was associated with shorter 6MWD [B = -2.69 m (95% CI = -4.69; -0.69)] and lower relative elbow extension strength (B = -0.01 Nm kg-1 (-0.02; 0.00). More sedentary breaks were associated with faster TCSTtime: B = -0.55 s (-0.85; -0.26). Longer average sedentary bout duration was associated with slower TCSTtime [B = 0.17 s (0.09; 0.25)] and lower knee extension strength [B = -0.01 Nm kg-1 (-0.02; 0.00)]. Every hour of PA and HPA were associated with greater 6MWD [BPA = 15.88 m (9.87; 21.89), BHPA = 40.72 m (30.18; 51.25)], faster TCSTtime [BPA = -0.55 s (-1.03; -0.07), BHPA = -2.25 s (-3.09; -1.41)], greater elbow flexion strength [BPA = 0.03 Nm kg-1 (0.01; 0.07)], [BHPA = 0.05 Nm kg-1 (0.01; 0.08)], and greater knee extension strength [BPA = 0.04 Nm kg-1 (0.01; 0.07)], [BHPA = 0.13 Nm kg-1 (0.06; 0.20)]. Conclusion: In adults aged 40-75 years, sedentary behavior appeared to be marginally associated with lower physical function, independent of HPA. This suggests that merely reducing sedentary behavior is insufficient to improve/maintain physical function. In contrast, engaging regularly in PA, in particular HPA, is important for physical function.

Integrated nutritional intervention in the elderly after hip fracture. A process evaluation.

BACKGROUND & AIMS: Within a multicentre randomized controlled trial aimed at improving the nutritional status and increase the speed of recovery of elderly hip fracture patients, we performed a process evaluation to investigate the feasibility of the intervention within the present Dutch health care system. METHODS: Patients in the intervention group received nutritional counseling during 10 contacts. Oral nutritional supplements were advised as needed until three months after hip fracture surgery. The intervention was evaluated with respect to dieticians' adherence to the study protocol, content of nutritional counseling, and patients' adherence to recommendations given. RESULTS: We included 66 patients (mean age of 76, range 55-92 years); 74% women. Eighty-three percent of patients received all 10 contacts as planned, but in 62% of the patients one or more telephone calls had to be replaced by face to face contacts. Nutritional counseling was complete in 91% of contacts. Oral nutritional supplementation was needed for a median period of 76 days; 75% of the patients took the oral nutritional supplements as recommended. CONCLUSIONS: Nutritional counseling in elderly hip fracture patients through face to face contacts and telephone calls is feasible. However, individual tailoring of the intervention is recommended. The majority of hip fracture patients needed >2 months oral nutritional supplements to meet their nutritional requirements. The trial was registered at clincialtrails.gov as NCT00523575.

Efficacy and cost-effectiveness of nutritional intervention in elderly after hip fracture: design of a randomized controlled trial.

BACKGROUND: Hip fracture patients often have an impaired nutritional status at the time of fracture, which can result in a higher complication rate, prolonged rehabilitation time and increased mortality. A study was designed to evaluate the effect of nutritional intervention on nutritional status, functional status, total length of stay, postoperative complications and cost-effectiveness. METHODS: Open-labelled, multi-centre, randomized controlled trial in hip fracture patients aged 55 years and above. The intervention group receives dietetic counselling (by regular home visits and telephone calls) and oral nutritional supplementation for three months after surgery. The control group receives usual dietetic care as provided by the hospital. Outcome assessment is performed at three and six months after hip fracture. DISCUSSION: Patient recruitment has started in July 2007 and has ended in December 2009. First results are expected in 2011. TRIAL REGISTRATION: ClinicalTrials.gov NCT00523575.

A rational approach to nutritional assessment.

BACKGROUND & AIMS: Consensus regarding definitions of malnutrition and methods to assess nutritional state is lacking. We propose a definition and its operationalization. METHODS: A definition was formulated on the basis of the pathophysiology of malnutrition, while reviewing the metabolic and physiological characteristics of different populations, considered to be malnourished. The definition was operationalized to yield measures to perform nutritional assessment. RESULTS: Malnutrition was defined as "a subacute or chronic state of nutrition in which a combination of varying degrees of over- or undernutrition and inflammatory activity has led to a change in body composition and diminished function". Its operationalization led to four elements that may serve as the basis of nutritional assessment: (1) measurement of nutrient balance, (2) measurement of body composition, (3) measurement of inflammatory activity, and (4) measurement of muscle, immune and cognitive function. Most elements measured should be validated with gold standards; normal values should be obtained in different populations. Values obtained in people considered to be at nutritional risk should be related to outcome. CONCLUSION: A definition is proposed that reflects the pathophysiology of malnutrition and that, when operationalized, will lead to measures reflecting this pathophysiology. Such an approach may yield comparable and reproducible rates and degrees of malnutrition in populations as well as in individuals.

SGA and measures for muscle mass and strength in surgical Vietnamese patients.

OBJECTIVE: This study compared the outcome of the Subjective Global Assessment (SGA) in preoperative surgical patients with objective measurements of muscle mass and strength and with biochemical data. A secondary aim was to test the influence of inflammatory activity on muscle strength. METHODS: Two hundred seventy-four consecutive patients who were admitted for elective major abdominal surgery were assessed using the SGA, anthropometry, muscle strength, and laboratory measurements (hemoglobin, protein, albumin, C-reactive protein, and lymphocytes). Normal values for midarm muscle circumference (MAMC) and handgrip strength were obtained in a healthy control group. For all other variables, normal values available for the Vietnamese population were used. RESULTS: Of 274 patients (151 men, 123 women) assessed, 61 (22.3%) were classified as SGA class A (well nourished), 97 patients (35.4%) as class B (moderately malnourished), and 116 patients (42.3%) as class C (severely malnourished). There were significant differences in age, body weight, percentage of weight loss, triceps skinfold thickness, MAMC, and serum albumin across the three SGA classes. Almost all patients rated class A had normal MAMC and handgrip strength. However, a large proportion of patients rated as B or C also had normal MAMC and handgrip strength (38% of men, 50% of women). Handgrip strength per square meter correlated with serum albumin (r = 0.278, P < 0.001) and this correlation persisted when handgrip strength was controlled for MAMC (r = 0.296, P < 0.001 in men; r = 0.237, P < 0.01 in women). CONCLUSION: The SGA correctly identifies patients with normal muscle mass and strength but a substantial number of patients rated SGA B or C have normal muscle mass and strength. Muscle strength is not only positively associated with muscle mass but also negatively with inflammatory activity.

Bioelectrical impedance measurements in patients with gastrointestinal disease: validation of the spectrum approach and a comparison of different methods for screening for nutritional depletion.

BACKGROUND: Bioelectrical impedance spectroscopy (BIS) may be of value in identifying patients with nutritional depletion. OBJECTIVE: The primary aim of the study was to assess the validity of BIS in patients with gastrointestinal disease. The secondary aim was to compare different screening methods for identifying nutritionally depleted patients. DESIGN: In 70 patients with gastrointestinal disease, BIS measurements were performed and fluid compartments were calculated from extrapolated resistance (R) values of extracellular (R(ECW)) and intracellular (R(ICW)) water based on mixture equations. Results were compared with total body water and ECW, which were measured by dilution methods. Patients were classified as depleted if their actual fat-free mass (FFM) was <90% of their ideal FFM (iFFM). Different screening approaches for depletion were compared: the impedance vector method and the resistance index (RI) in relation to iFFM (RI/iFFM). RESULTS: Total body water and ICW were largely underestimated (4 L) in the not-depleted patients but not in the depleted patients. In both groups, ECW was slightly overestimated (0.6-0.7 L). The critical frequency was 60% higher and the membrane capacitance was 40% lower in the depleted than in the not-depleted patients. The impedance vector method failed to identify depleted patients, whereas the proposed ratio at R(50) (R measured at 50 kHz) and R(inf) (R at infinite frequency) resulted in comparable sensitivity (86%) and specificity (73-80%). CONCLUSIONS: BIS measures of body fluids are influenced by the presence of depletion, probably because of alterations in the electric properties of the body at the cellular level. However, for screening purposes, the use of the ratio (L(2)/R)/iFFM at R(50) and R(inf) may be of value.

Accuracy of bioelectrical impedance spectroscopy in measuring changes in body composition during severe weight loss.

BACKGROUND: Bioelectrical impedance spectroscopy (BIS) is an attractive method for measuring body composition because it is noninvasive, simple, and cheap. The effect of obesity on the accuracy of impedance measurements has been recognized for some time, but no conclusive explanations or ways to correct the measurement errors have been published. We studied the effect of the composition of weight loss on the accuracy of BIS to measure changes in body fluid volumes during severe weight loss. Within subjects the effect of variable losses of fat mass was studied. METHODS: In 10 morbidly obese female subjects who underwent gastric reduction surgery, changes in total body water (TBW) and extracellular water (ECW) were monitored for 1 year by deuterium (Deu) and bromide (Br) dilution and by BIS. Measurements were performed before the operation and after 2 weeks, 3 months, and 1 year. Extrapolated resistance values of extracellular (Recw) and intracellular water (Ricw) were used in mixture equations for calculating the corresponding fluid volumes. RESULTS: After 1 year, weight decreased by 53 kg, TBW (Deu) loss was 8.7 L, and ECW (Br) loss was 4.3 L. Comparison of BIS with reference methods for measuring all possible changes over 6 time-intervals revealed a mean overestimation of TBW (2.4 L, SD = 2.9) and ECW (0.74 L, SD = 2.6) losses by BIS. Overestimation increased significantly with increasing fat losses, expressed as percentage fat of the weight loss and as change in triceps skinfolds. Measured changes in Recw and Ricw were less than expected for an ideal agreement between dilution methods and mixture equations. CONCLUSIONS: BIS with the use of mixture equations overestimates fluid losses during weight loss. The error is associated with the amount of fat loss. The large contribution of the factor weight in the mixture equations is likely to be responsible. The assumptions of mixture theory are not valid in obesity.