Enteral/Parenteral Nutrition in Foals and Adult Horses Practical Guidelines for the Practitioner.

Nutritional support is an important adjunct to medical therapy in the sick, injured, or debilitated equine patient. What is not clear is the optimal route, composition, or amounts of support. The enteral route should be chosen whenever possible to maximize the benefits to the gastrointestinal tract and the patient as a whole. Complete or partial parenteral nutrition is most useful as a bridge during recovery and transition to enteral feeding in the horse. The reader is encouraged to consider nutritional support whether enteral or parenteral in any anorexic, chronically debilitated, or sick equine patient.

A Suitable Diet for Recovery from Starvation Is a High-Fat Diet, but Not a High-Protein Diet, in Rats.

The present study aims to determine the most suitable dietary balance of energy-producing nutrients for recovery from starvation. Rats were fed their standard high- carbohydrate diet (HCD, carbohydrate energy : protein energy : fat energy=71 : 18 : 11) for 7 d and then deprived of food for 3 d (short-term starvation) or 8 d (long-term starvation). The starved rats were then fed the HCD, a high-protein diet (HPD, 31 : 57 : 12), or a high-fat diet (HFD, 34 : 14 : 52) for 8 d. Rats had ad libitum access to drinking water throughout the experimental period, including the starvation period. The reference group was allowed free access to the HCD throughout the experimental period. Characteristically, increased drinking, increased urea nitrogen in the plasma and urine, and hypertrophy of the kidneys, were observed in the HPD group. Furthermore, the recovery of plasma glucose level was insufficient in this group. Therefore, administration of a HPD was contraindicated in recovery from starvation. The recovery of body weight after starvation was excellent in the HFD group. No effect on the metabolism of B-group vitamins involved in energy metabolism was found with the administration of any diet. The effects of HCD and HFD administration on recovery from starvation were investigated in further detail. No adverse effects were observed on the tissue to body weight mass ratios or biochemical parameters in blood in the HFD group. From the above findings, it is hypothesized that a HFD is most suitable for quickly reversing the influence of starvation.

Passive and active roles of fat-free mass in the control of energy intake and body composition regulation.

While putative feedback signals arising from adipose tissue are commonly assumed to provide the molecular links between the body's long-term energy requirements and energy intake, the available evidence suggests that the lean body or fat-free mass (FFM) also plays a role in the drive to eat. A distinction must, however, be made between a 'passive' role of FFM in driving energy intake, which is likely to be mediated by 'energy-sensing' mechanisms that translate FFM-induced energy requirements to energy intake, and a more 'active' role of FFM in the drive to eat through feedback signaling between FFM deficit and energy intake. Consequently, a loss of FFM that results from dieting or sedentarity should be viewed as a risk factor for weight regain and increased fatness not only because of the impact of the FFM deficit in lowering the maintenance energy requirement but also because of the body's attempt to restore FFM by overeating-a phenomenon referred to as 'collateral fattening'. A better understanding of these passive and active roles of FFM in the control of energy intake will necessitate the elucidation of peripheral signals and energy-sensing mechanisms that drive hunger and appetite, with implications for both obesity prevention and its management.

Unsatisfactory knowledge and use of terminology regarding malnutrition, starvation, cachexia and sarcopenia among dietitians.

BACKGROUND & AIMS: Clinical signs of malnutrition, starvation, cachexia and sarcopenia overlap, as they all imply muscle wasting to a various extent. However, the underlying mechanisms differ fundamentally and therefore distinction between these phenomena has therapeutic and prognostic implications. We aimed to determine whether dietitians in selected European countries have 'sufficient knowledge' regarding malnutrition, starvation, cachexia and sarcopenia, and use these terms in their daily clinical work. METHODS: An anonymous online survey was performed among dietitians in Belgium, the Netherlands, Norway and Sweden. 'Sufficient knowledge' was defined as having mentioned at least two of the three common domains of malnutrition according to ESPEN definition of malnutrition (2011): 'nutritional balance', 'body composition' and 'functionality and clinical outcome', and a correct answer to three cases on starvation, cachexia and sarcopenia. Chi-square test was used to analyse differences in experience, work place and number of malnourished patients treated between dietitians with 'sufficient knowledge' vs. 'less sufficient knowledge'. RESULTS: 712/7186 responded to the questionnaire, of which data of 369 dietitians were included in the analysis (5%). The term 'malnutrition' is being used in clinical practice by 88% of the respondents. Starvation, cachexia and sarcopenia is being used by 3%, 30% and 12% respectively. The cases on starvation, cachexia and sarcopenia were correctly identified by 58%, 43% and 74% respectively. 13% of the respondents had 'sufficient knowledge'. 31% of the respondents identified all cases correctly. The proportion of respondents with 'sufficient knowledge' was significantly higher in those working in a hospital or in municipality (16%, P < 0.041), as compared to those working in other settings (7%). CONCLUSIONS: The results of our survey among dietitians in four European countries show that the percentage of dietitians with 'sufficient knowledge' regarding malnutrition, starvation, cachexia and sarcopenia is unsatisfactory (13%). The terms starvation, cachexia and sarcopenia are not often used by dietitians in daily clinical work. As only one-third (31%) of dietitians identified all cases correctly, the results of this study seem to indicate that nutrition-related disorders are suboptimally recognized in clinical practice, which might have a negative impact on nutritional treatment. The results of our study require confirmation in a larger sample of dietitians.

Macronutrient Metabolism in Starvation and Stress.

In starvation and to a lesser extent in stress starvation, the loss of protein mass is spared as much as possible. This metabolic arrangement must have developed under the influence of evolutionary pressure in view of the importance of protein mass for function and longevity. Peripheral adipose tissue mass is only limiting when its mass is extremely small. Protein is the predominant precursor of glucose in (stress) starvation and glucose is an essential substrate for the synthesis and maintenance of cells and matrix and for the control of the redox state. To spare protein, glucose should be used efficiently only for those purposes that cannot be achieved by fat. It is suggested that this is achieved by limiting full glucose oxidation and increasing fatty acid and ketone body oxidation, which most likely can also largely cover energy needs of the central nervous system. In stress states, net negative nitrogen balance (catabolism) largely results from net losses of peripheral protein mass, predominantly muscles, whereas central organs (e.g. the liver), the immune system and wound healing are anabolic. A number of factors are responsible for a net negative nitrogen balance which may ultimately lead to death if stress persists. In stress, the amino acid mix derived from peripheral (predominantly muscle) tissues is modified in interplay with the liver and to a minor extent the kidney. This mix is different in nonstressed conditions, containing substantially increased amounts of the nonessential amino acids glutamine, alanine, glycine and (hydroxy)proline. Part of the amino acid skeletons released by muscles are substrates to produce glucose in the liver and kidney. Glucose and the amino acids produced especially serve as substrates for cell proliferation and matrix deposition. The catabolic processes in peripheral tissues cannot be countered completely by adequate nutritional support as long as stress persists. This metabolic arrangement dictates a nutritional mix containing liberal amounts of protein and carbohydrates and addition of lipids to cover energy requirements.

Refractory hypoglycemia and subsequent cardiogenic shock in starvation and refeeding: report of three cases.

OBJECTIVE: Although starvation is associated with high in-hospital mortality, its related cardiac complications are not sufficiently understood. The aim of this study was to determine the clinical course and pathogenesis of cardiac complications in malnourished patients. METHODS: We reviewed three cases of hypoglycemia and hypotriglyceridemia with cardiac complications in starvation. RESULTS: This report concerns three patients, respectively suffering from anorexia nervosa, esophageal carcinoma, and Parkinson's disease. Their ages ranged from 18 to 70 y, body mass index was 11.5 ± 1.5 kg/m2 (mean ± SD), and the main symptom was coma. The average blood glucose level was 15.7 ± 7.8 mg/dL without any history of insulin use or diabetes mellitus. In all cases, hypoglycemia was refractory and repetitive so that continuous glucose administration was required to maintain euglycemia. Serum triglyceride and non-esterified fatty acid levels were also very low (7 ± 4 mg/dL and 10 ± 9.1 µEq/L, respectively). Levels of serum potassium, phosphate, and magnesium were almost normal at admission. The main cardiac complications included Takotsubo cardiomyopathy and cardiac arrest. All patients survived as a result of intensive treatment. CONCLUSIONS: Repetitive severe hypoglycemia without known background causes should be viewed as an important sign. Once this occurs, the administration of a much higher caloric input than usual accompanied by intensive monitoring will be required to maintain appropriate glucose levels. The early identification of such patients seems to be essential to reduce the high risk for cardiac complications during starvation and refeeding.

Management of starvation in a Role 1 setting.

Historical reports from war and natural disasters first identified the dangers of reintroducing food after a period of starvation or malnutrition. The development of advanced nutritional support for hospitalised patients gave rise to the concept of refeeding syndrome, further highlighting the problems and leading to the development of guidelines and protocols for managing malnutrition. In this paper we present a case of starvation in the maritime setting and review the pathophysiology of starvation and refeeding. We discuss the problems associated with managing acute starvation in a Role 1 setting without access to higher medical care, and present guidance for its management.

How dieting makes some fatter: from a perspective of human body composition autoregulation.

Dieting makes you fat - the title of a book published in 1983 - embodies the notion that dieting to control body weight predisposes the individual to acquire even more body fat. While this notion is controversial, its debate underscores the large gap that exists in our understanding of basic physiological laws that govern the regulation of human body composition. A striking example is the key role attributed to adipokines as feedback signals between adipose tissue depletion and compensatory increases in food intake. Yet, the relative importance of fat depletion per se as a determinant of post-dieting hyperphagia is unknown. On the other hand, the question of whether the depletion of lean tissues can provide feedback signals on the hunger-appetite drive is rarely invoked, despite evidence that food intake during growth is dominated by the impetus for lean tissue deposition, amidst proposals for the existence of protein-static mechanisms for the regulation of growth and maintenance of lean body mass. In fact, a feedback loop between fat depletion and food intake cannot explain why human subjects recovering from starvation continue to overeat well after body fat has been restored to pre-starvation values, thereby contributing to 'fat overshooting'. In addressing the plausibility and mechanistic basis by which dieting may predispose to increased fatness, this paper integrates the results derived from re-analysis of classic longitudinal studies of human starvation and refeeding. These suggest that feedback signals from both fat and lean tissues contribute to recovering body weight through effects on energy intake and thermogenesis, and that a faster rate of fat recovery relative to lean tissue recovery is a central outcome of body composition autoregulation that drives fat overshooting. A main implication of these findings is that the risk of becoming fatter in response to dieting is greater in lean than in obese individuals.

Refeeding syndrome.

Refeeding syndrome (RFS) is the result of aggressive enteral or parenteral feeding in a malnourished patient, with hypophosphatemia being the hallmark of this phenomenon. Other metabolic abnormalities, such as hypokalemia and hypomagnesemia, may also occur, along with sodium and fluid retention. The metabolic changes that occur in RFS can be severe enough to cause cardiorespiratory failure and death. This article reviews the pathophysiology, the clinical manifestations, and the management of RFS. The key to prevention is identifying patients at risk and being aware of the potential complications involved in rapidly reintroducing feeds to a malnourished patient.

Serum levels of S100B are decreased in chronic starvation and normalize with weight gain.

S100B protein is mainly synthesized in glial cells and modulates the balance between cell proliferation and differentiation in neurons and glial cells. However, S100B is not CNS-specific since its production was detected in numerous non-cerebral tissues e.g. adipocytes. In this study we investigated the influence of chronic fasting and subsequent weight gain on serum levels of S100B in patients with anorexia nervosa. We found that nutritional status was an important factor influencing serum levels of S100B.

Chronically starved horses: predicting survival, economic, and ethical considerations.

Nine of 45 horses subjected to prolonged malnutrition died subsequent to being placed with a responsible caregiver and being provided an appropriate diet. Initial extreme poor body condition score tended to be associated with death, although individual response to refeeding varied. The financial costs of stabilizing the group of horses significantly exceeded their free market price. Responsible management of chronically starved commercial animals should include options for immediate euthanasia.

A retrospective study of presentation, treatment, and outcome of free-ranging raptors in Greece (1997-2000).

A retrospective study was conducted on free-ranging raptors (n = 402) presented to the Veterinary Medical Teaching Hospital, School of Veterinary Medicine, Aristotle University of Thessaloniki, Greece, during a 3-yr period (1997-2000). Representatives of 19 species were admitted from taxonomic orders Accipitriformes (n = 295), Falconiformes (n = 35), and Strigiformes (n = 72). Traumatic injuries (n = 305, 75.8%) were the most common cause of presentation in all raptors. Starvation (n = 38 birds, 9.4%) was the second most common reason, whereas toxicoses (n = 28, 6.9%) were suspected in a limited number of birds. Orphans (n = 31, 7.7%) were presented during breeding season primarily because of inappropriate human intervention. Surgical and medical treatment was given to all birds when necessary. In total, 229 (56.9%) of the presented raptors were successfully rehabilitated and released, 121 (30%) were rehabilitated but nonreleasable, whereas 52 (12.9%) of them died despite treatment. Human intervention (79.2%) plays the most important role in birds of prey morbidity and mortality.

Selective feeding centres in refugee settings: evaluation framework protocol.

Selective feeding programs are centres for the treatment of persons suffering from acute malnutrition. Unlike chronic malnutrition, acute malnutrition reflects recent problems. In a crisis situation, wasting is preferred above other indicators because it is sensitive to rapid change, indicates present change, can be used to monitor the impact of interventions and is a good predictor of immediate mortality risk. This paper reviews the current approach being used in the field to evaluate the effectiveness of feeding programs. There is no comprehensive evaluation framework in place to assess the impact of feeding programs on mortality due to malnutrition. Some loose outcome measures, such as the number of children enrolled in a feeding centre, are being used to determine if a feeding centre should continue. In addition, malnutrition prevalence and crude mortality rates determined through nutritional and mortality surveys are used to assess the impact of feeding programs. This procedure does not take into account potential confounding factors that impact on malnutrition prevalence, including access to non-relief foods and the general food ration. Therefore, one could not confidently say that the reduction of malnutrition prevalence is a result of feeding programs. This paper presents an alternative approach to evaluating feeding centres.