Fracture risk assessment in celiac disease: a registry-based cohort study.

Celiac disease is associated with an increased fracture risk but is not a direct input to the FRAX® calculation. When celiac disease is considered as a secondary osteoporosis risk factor or BMD is included in the FRAX assessment, FRAX accurately predicts fracture risk. INTRODUCTION: The fracture risk assessment tool (FRAX®) uses clinical factors and bone mineral density (BMD) measurement to predict 10-year major osteoporotic (MOF) fracture probability. The study aim was to determine whether celiac disease affects MOF risk independent of FRAX score. METHODS: The Manitoba BMD Registry includes clinical data, BMD measurements, 10-year probability of MOF calculated for each individual using the Canadian FRAX tool and diagnosed celiac disease. Using linkage to population-based healthcare databases, we identified incident MOF diagnoses over the next 10 years for celiac disease and general population cohorts. RESULTS: Celiac disease (N = 693) was associated with increased fracture risk adjusted for FRAX score computed without secondary osteoporosis or BMD (adjusted hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.11-1.86). Celiac disease was no longer a significant risk factor for fracture when secondary osteoporosis or BMD were included in the FRAX calculation (p > 0.1). In subjects with celiac disease, each SD increase in FRAX score (calculated with and without secondary osteoporosis or BMD) was associated with higher risk of incident MOF (adjusted HR 1.66 to 1.80), similar to the general population (p-interaction > 0.2). Including celiac disease as secondary osteoporosis or including BMD in FRAX 10-year MOF probability calculations (10.1% and 8.6% respectively) approximated the observed cumulative 10-year MOF probability (10.8%, 95% CI 7.8-13.9%). CONCLUSIONS: Celiac disease is associated with an increased risk of major osteoporotic fractures. When celiac disease is considered as a secondary osteoporosis risk factor or BMD is included in FRAX assessment, FRAX accurately predicts fracture risk.

Patient-reported dietetic care post hospital for free-living patients: a Canadian Malnutrition Task Force Study.

BACKGROUND: Transitions out of hospital can influence recovery. Ideally, malnourished patients should be followed by someone with nutrition expertise, specifically a dietitian, post discharge from hospital. Predictors of dietetic care post discharge are currently unknown. The present study aimed to determine the patient factors independently associated with 30-days post hospital discharge dietetic care for free-living patients who transitioned to the community. METHODOLOGY: Nine hundred and twenty-two medical or surgical adult patients were recruited in 16 acute care hospitals in eight Canadian provinces on admission. Eligible patients could speak English or French, provide their written consent, were anticipated to have a hospital stay of ≥2 days and were not considered palliative. Telephone interviews were completed with 747 (81%) participants using a standardised questionnaire to determine whether dietetic care occurred post discharge; 544 patients discharged to the community were included in the multivariate analyses, excluding those who were admitted to nursing homes or rehabilitation facilities. Covariates during and post hospitalisation were collected prospectively and used in logistic regression analyses to determine independent patient-level predictors. RESULTS: Dietetic care post discharge was reported by 61/544 (11%) of participants and was associated with severe malnutrition [Subjective Global Assessment category C: odd's ratio (OR) 2.43 (1.23-4.83)], weight loss post discharge [(OR 2.86 (1.45-5.62)], comorbidity [(OR 1.09 (1.02-1.17)] and a dietitian consultation on admission [(OR 3.41 (1.95-5.97)]. CONCLUSIONS: Dietetic care post discharge occurs in few patients, despite the known high prevalence of malnutrition on admission and discharge. Dietetic care in hospital was the most influential predictor of post-hospital care.

Prevalence and predictors of weight change post discharge from hospital: a study of the Canadian Malnutrition Task Force.

BACKGROUND/OBJECTIVES: Little is known about factors associated with weight change post discharge from hospital; yet poor nutritional status in the transition from hospital to community can result in readmission. This exploratory study aimed to determine the factors associated with weight change 30 days post discharge defined as weight gain (WG; 5+ pounds), weight loss (WL; 5+pounds) or weight stable (WS). SUBJECTS/METHODS: A total of 922 medical or surgical patients were recruited from 16 acute care hospitals in 8 Canadian provinces. Telephone interviews were completed with 747 (81%) participants 30 days post discharge using a standardized questionnaire that included: self-reported weight change, assessment of appetite, usage of healthcare services and supports for food-related activities of daily living. Covariates collected during hospitalization, including nutritional status at discharge evaluated by subjective global assessment (SGA), were used in logistic regressions. RESULTS: Among the 747 patients, 26% reported WL, 16.7% had WG and 57.2% were WS. Those with WG were: younger (odds ratio (OR) 0.77 (0.69, 0.85)), male (OR 1.71 (1.12, 2.61)), malnourished at discharge (SGA B OR 2.13 (1.36, 3.33), SGA C OR 2.76 (1.19, 6.62)), and had a good appetite based on the low OR for fair/poor appetite (OR 0.28 (0.11, 0.66)). WL was associated with being on a special diet (OR 1.45 (1.07,1.96)) and reporting fair/poor appetite (OR 2.67 (1.76, 4.07)). CONCLUSIONS: Weight change was relatively common with WL predominating. Several variables were identified to be predictors of WL or weight gain, with appetite being common to both. Future work to further define and confirm these associations is warranted.

Symptomatic suspected gluten exposure is common among patients with coeliac disease on a gluten-free diet.

BACKGROUND: A gluten-free diet is the only recommended treatment for coeliac disease. AIM: To determine the prevalence and characteristics of reactions to gluten among persons with coeliac disease on a gluten-free diet. METHODS: Adults with biopsy proven, newly diagnosed coeliac disease were prospectively enrolled. A survey related to diet adherence and reactions to gluten was completed at study entry and 6 months. The Coeliac Symptom Index, Coeliac Diet Assessment Tool (CDAT) and Gluten-Free Eating Assessment Tool (GF-EAT) were used to measure coeliac disease symptoms and gluten-free diet adherence. RESULTS: Of the 105 participants, 91% reported gluten exposure <1 per month and median CDAT score was 9 (IQR 8-11), consistent with adequate adherence. A suspected symptomatic reaction to gluten was reported by 66%. Gluten consumption was unsuspected until a reaction occurred (63%) or resulted from problems ordering in a restaurant (29%). The amount of gluten consumed ranged from cross-contact (30%) to a major ingredient (10%). Median time to symptom onset was 1 h (range 10 min to 48 h), and median symptom duration was 24 h (range 1 h to 8 days). Common symptoms included abdominal pain (80%), diarrhoea (52%), fatigue (33%), headache (30%) and irritability (29%). CONCLUSIONS: Reactions to suspected gluten exposure are common among patients with coeliac disease on a gluten-free diet. Eating at restaurants and other peoples' homes remain a risk for unintentional gluten exposure. When following individuals with coeliac disease, clinicians should include questions regarding reactions to gluten as part of their assessment of gluten-free diet adherence.

Living gluten-free: adherence, knowledge, lifestyle adaptations and feelings towards a gluten-free diet.

BACKGROUND: A gluten-free diet (GFD) requires tremendous dedication, involving substantive changes to diet and lifestyle that may have a significant impact upon quality of life. The present study aimed io assess dietary adherence, knowledge of a GFD, and the emotional and lifestyle impact of a GFD. METHODS: Community dwelling adults following a GFD completed a questionnaire with items related to reasons for avoiding gluten, diagnostic testing, GFD adherence, knowledge and sources of information about a GFD, the Work and Social Adjustment Scale, and the effect of a GFD diet on lifestyle, feelings and behaviours. RESULTS: Strict GFD adherence among the 222 coeliac disease (CD) patients was 56%. Non-CD individuals (n = 38) were more likely to intentionally ingest gluten (odds ratio = 3.7; 95% confidence interval = 1.4-9.4). The adverse impact of a GFD was modest but most pronounced in the social domain. Eating shifted from the public to the domestic sphere and there were feelings of social isolation. Affective responses reflected resilience because acceptance and relief were experienced more commonly than anxiety or anger. Non-CD respondents were less knowledgeable and less likely to consult health professionals. They experienced less anger and depression and greater pleasure in eating than CD respondents. CONCLUSIONS: The findings obtained in the present suggest there is good potential for positive adaptation to the demands of a GFD; nevertheless, there is a measurable degree of social impairment that merits further study. The GFD may be a viable treatment option for conditions other than CD; however, education strategies regarding the need for diagnostic testing to exclude CD are required.

Barriers to food intake in acute care hospitals: a report of the Canadian Malnutrition Task Force.

BACKGROUND: Poor food intake is common in acute care patients and can exacerbate or develop into malnutrition, influencing both recovery and outcome. Yet, research on barriers and how they can be alleviated is lacking. The present study aimed to (i) describe the prevalence of food intake barriers in diverse hospitals and (ii) determine whether patient, care or hospital characteristics are associated with the experience of these barriers. METHODS: Patients (n = 890; 87%) completed a validated questionnaire on barriers to food intake, including perceptions of food quality, just before their discharge from a medical or surgical unit in each of 18 hospitals across Canada. Scores were created for barrier domains. Associations between these barriers and selected patient characteristics collected at admission or throughout the hospital stay and site characteristics were determined using bivariate analyses. RESULTS: Common barriers were being interrupted at meals (41.8%), not being given food when a meal was missed (69.2%), not wanting ordered food (58%), loss of appetite (63.9%) and feeling too sick (42.7%) or tired (41.1%) to eat. Younger patients were more likely (P < 0.0001) to report being disturbed at meals (44.6%) than older patients (33.9%) and missing a meal for tests (39.0% versus 31.0%, P < 0.05). Patients who were malnourished, women, those with more comorbidity, and those who ate <50% of the meal reported several barriers across domains. CONCLUSIONS: The present study confirms that barriers to food intake are common in acute care hospitals. This analysis also identifies that specific patient subgroups are more likely to experience food intake barriers. Because self-reported low food intake in hospital was associated with several barriers, it is relevant to consider assessing, intervening and monitoring barriers to food intake during the hospital stay.

Validity and reliability of the new Canadian Nutrition Screening Tool in the 'real-world' hospital setting.

BACKGROUND/OBJECTIVES: Nutrition screening should be initiated on hospital admission by non-dietitians. This research aimed to validate and assess the reliability of the Canadian Nutrition Screening Tool (CNST) in the 'real-world' hospital setting. SUBJECTS/METHODS: Adult patients were admitted to surgical and medical wards only (no palliative patients). Study 1--Nutrition Care in Canadian Hospitals (n=1014): development of the CNST (3 items: weight loss, decrease food intake, body mass index (BMI)) and exploratory assessment of its criterion and predictive validity. Study 2--Inter-rater reliability and criterion validity assessment of the tool completed by untrained nursing personnel or diet technician (DT) (n=150). Subjective Global Assessment performed by site coordinators was used as a gold standard for comparison. RESULTS: Study 1: The CNST completed by site coordinators showed good sensitivity (91.7%) and specificity (74.8%). Study 2: In the subsample of untrained personnel (160 nurses; one DT), tool's reliability was excellent (Kappa=0.88), sensitivity was good (>90%) but specificity was low (47.8%). However, using a two-item ('yes' on both weight change and food intake) version of the tool improved the specificity (85.9%). BMI was thus removed to promote feasibility. The final two-item tool (study 1 sample) has a good predictive validity: length of stay (P<0.001), 30-day readmission (P=0.02; X(2) 5.92) and mortality (P<0.001). CONCLUSIONS: The simple and reliable CNST shows good sensitivity and specificity and significantly predicts adverse outcomes. Completion by several untrained nursing personnel confirms its utility in the nursing admission assessment.

Providing quality nutrition care in acute care hospitals: perspectives of nutrition care personnel.

BACKGROUND: Malnutrition is common in acute care hospitals worldwide and nutritional status can deteriorate during hospitalisation. The aim of the present qualitative study was to identify enablers and challenges and, specifically, the activities, processes and resources, from the perspective of nutrition care personnel, required to provide quality nutrition care. METHODS: Eight hospitals participating in the Nutrition Care in Canadian Hospitals study provided focus group data (n = 8 focus groups; 91 participants; dietitians, dietetic interns, diet technicians and menu clerks), which were analysed thematically. RESULTS: Five themes emerged from the data: (i) developing a nutrition culture, where nutrition practice is considered important to recovery of patients and teams work together to achieve nutrition goals; (ii) using effective tools, such as screening, evidence-based protocols, quality, timely and accurate patient information, and appropriate and quality food; (iii) creating effective systems to support delivery of care, such as communications, food production and delivery; (iv) being responsive to care needs, via flexible food systems, appropriate menus and meal supplements, up to date clinical care and including patient and family in the care processes; and (v) uniting the right person with the right task, by delineating roles, training staff, providing sufficient time to undertake these important tasks and holding staff accountable for their care. CONCLUSIONS: The findings of the present study are consistent with other work and provide guidance towards improving the nutrition culture in hospitals. Further empirical work on how to support successful implementation of nutrition care processes is needed.

Prescription of trace elements in adults on home parenteral nutrition: current practice based on the Canadian Home Parenteral Nutrition Registry.

BACKGROUND: Since the introduction of long-term parenteral nutrition (PN), morbidity due to inadequate replacement or toxicity of routinely administered trace elements has been well described. After decades of experience, much debate still exists about optimal supplementation. In practice, trace elements (TEs) seem to be frequently provided by prescribing an all-inclusive commercial multi-TE admixture with little dosage flexibility. AIM: Our goal was to review TE supplementation practice among 5 PN support centers across Canada, through a retrospective review of the Canadian Home PN Registry. METHODS: Baseline demographic, clinical, and biochemical parameters along with information regarding the PN prescription of 135 patients with complete records were retrieved from the registry database collected between 2005 and 2007. TE supplementation prescriptions were compared with recent guidelines as well as between groups of patients with different PN indications and dietary intake status. Consent was signed by all participating patients. RESULTS: The average daily PN concentrations of TE were as follows: zinc, 8.6 ± 5.5 mg (130.92 ± 84.23 µmol); manganese, 452 ± 184 µg (8.22 ± 3.34 µmol); selenium, 78 ± 45 µg (0.99 ± 0.57 µmol); chromium, 11 ± 5 µg (0.21 ± 0.10 µmol); copper, 0.64 ± 0.35 mg (10.11 ± 5.58 µmol); and iodine, 77 ± 42 µg (0.61 ± 0.33 µmol). The mean daily supplementation of zinc, manganese, copper, and selenium exceeded published recommendations. Patients' underlying anatomy or indication for PN did not significantly influence decisions regarding replacement standards. CONCLUSION: Parenteral TE supplementation in Canadian PN programs needs to be reviewed and adjusted according to most current guidelines. This may require a reevaluation of the commercial TE preparations currently available in Canada and potential new products worldwide to avoid oversupplementation and potential toxicity.

A comparison of antibody testing, permeability testing, and zonulin levels with small-bowel biopsy in celiac disease patients on a gluten-free diet.

Active celiac disease is associated with positive endomysial (EMA) and tissue transglutaminase (TTG) antibodies, elevated zonulin levels, and increased intestinal permeability. There is little known about what happens to these immunologic and structural abnormalities in patients on a gluten-free diet and their correlation with small-bowel biopsy changes. Adult patients previously diagnosed with celiac disease and on a gluten-free diet for greater than 1 year were considered for the study. All patients underwent the following: measurement of EMA and TTG antibodies, serum zonulin levels, intestinal permeability (IP) testing with lactulose/mannitol ratios, food diary analysis for gluten ingestion and small- bowel biopsy. A total of 21 patients on a gluten-free diet for a mean of 9.7 years completed the study. There were ten patients who had normalization of intestinal biopsies, IP and TTG, and EM antibodies. Six patients had Marsh type 2 or 3 lesions and all had either abnormal IP (5/6) or TTG antibody (4/6). In patients with Marsh type 3 lesions, there was a correlation between IP and zonulin levels. A subgroup of patients with celiac disease on a gluten-free diet has complete normalization of intestinal biopsies, intestinal permeability defects, and antibody levels. Patients with Marsh type 3 lesions have abnormal TTG antibodies and intestinal permeability with zonulin levels that correlate with IP. These abnormalities may be due to continued gluten ingestion. Further study is needed to determine the clinical utility of TTG antibodies and IP testing in following patients with celiac disease.

Anabolic steroids in COPD: a review and preliminary results of a randomized trial.

Patients with severe chronic obstructive pulmonary disease (COPD) commonly develop weight loss, muscle wasting, and consequently poor survival. Nutritional supplementation and anabolic steroids increase lean body mass, improve muscle strength, and survival in patients enrolled in comprehensive rehabilitation programs. Whether anabolic steroids are effective outside an intensive rehabilitation program is not known. We conducted a prospective, double-blind, placebo-controlled, 16-week trial to study the benefits of anabolic steroids in patients with severe COPD who did not participate in a structured rehabilitation program. Biweekly intramuscular injections of either the drug (nandrolone decanoate) or placebo were administered. Sixteen patients with severe COPD were randomized to either placebo or nandrolone decanoate. The placebo group weighed 55.32 +/- 11.33 kg at baseline and 54.15 +/- 10.80 kg at 16 weeks; the treatment group weighed 68.80 +/- 6.58 at baseline and 67.92 +/- 6.73 at 16 weeks. Lean body mass remained unchanged, 71 +/- 6 vs. 71 +/- 7 kg in placebo group and 67 +/- 7 vs. 67 +/- 7 in treatment group, at baseline and 16 weeks respectively. The distance walked on 6 min was unchanged at baseline, 8 weeks, and 16 weeks in placebo (291.17 +/- 134.83, 282.42 +/- 115.39, 286.00 +/- 82.63 m) and treatment groups (336.13 +/- 127.59, 364.83 +/- 146.99, 327.00 +/- 173.73 m). No improvement occurred in forced expiratory volume in one second, forced vital capacity, maximal inspiratory pressure, maximal expiratory pressure, VO(2) max or 6-min walk distance or health related quality of life. Administration of anabolic steroids (nandrolone decanoate) outside a dedicated rehabilitation program did not lead to either weight gain, improvement in physiological function, or better quality of life in patients with severe COPD.

Ulcerative colitis and Sweet's syndrome: a case report and review of the literature.

A 47-year-old man with a history of ulcerative colitis on prednisone and azathioprine was admitted to the hospital with a four-day history of fever, skin rash, arthralgias and leukocytosis. A skin biopsy demonstrated neutrophilic infiltration of the dermis that was consistent with Sweet's syndrome. He improved after several days with an increase in his prednisone and azathioprine. Sweet's syndrome is a rare cutaneous manifestation of inflammatory bowel disease, with approximately 40 cases reported in the literature. In a previously reported case of a patient with ulcerative colitis-associated Sweet's syndrome who was on azathioprine at the time of the skin eruption, the azathioprine was stopped, raising the possibility of drug-induced Sweet's syndrome. In the present case, the azathioprine was actually increased with complete resolution of the skin manifestations. This would support the theory that immunosuppressive therapy is the mainstay of therapy for this condition. In conclusion, Sweet's syndrome is a neutrophilic dermatosis that is rarely associated with ulcerative colitis. It may occur while on immunosuppressive therapy and responds to an intensification of immunosuppression.

Intestinal permeability in long-term follow-up of patients with celiac disease on a gluten-free diet.

Intestinal permeability is frequently abnormal in patients with celiac disease. The long-term effect of a gluten-free diet on intestinal permeability and the correlation of intestinal permeability with a gluten-free diet are not known. The objectives of this study were to determine the responses of intestinal permeability and antibody testing to gluten free diet and the degree of correlation of these measurements with gluten ingestion. In this prospective study, patients with celiac disease were divided into three groups based on length of time on a gluten-free diet: Group A, < 1 month; Group B, 1 month-1 year; Group C, > 1 year. Patients in Groups B and C were tested at baseline and at 4-12 weeks later for the following: lactulose/mannitol intestinal permeability, endomysial antibody, and 3-day food record. Permeability tests were also performed in Group A and control subjects. Intestinal permeability was elevated in newly diagnosed celiac disease and in individuals on a gluten-free diet for less than 1 year. Intestinal permeability was normal in 80% at visit 1 and 87% at visit 2 in individuals with celiac disease on a gluten-free diet for more than a year. Trace gluten ingestion was associated with increased intestinal permeability on visit 2 (P = 0.0480). The sensitivity of detecting gluten ingestion as measured by a 3-day food record was higher for permeability testing (29 and 36%) compared with endomysial antibody testing (18 and 18%) for visits 1 and 2, respectively. Intestinal permeability normalizes in the majority of individuals with celiac disease on a gluten-free diet. Gluten ingestion as measured by a 3-day food record correlates with intestinal permeability measurements. The role of permeability testing in the follow-up of patients with celiac disease warrants further investigation.

A comparison of the effect of elemental and immune-enhancing polymeric jejunal feeding on exocrine pancreatic function.

BACKGROUND: There are few studies examining the effect of jejunal feeding on pancreatic exocrine output. The purpose of this study was to compare the effects of jejunal feeding with an elemental formula (EF) and with a polymeric immune-enhancing formula (PIEF) on pancreatic exocrine function. METHODS: Patients undergoing a partial pancreatectomy had a jejunal feeding tube inserted and a pancreatic stent exteriorized, facilitating collection of pancreatic secretions. Postoperatively, patients underwent a secretin-stimulation test to document adequate pancreatic reserve. Patients were then randomized to receive jejunal feeding with EF or with PIEF for a 24-hour period, followed by a washout period of feeding with dextrose, and subsequent jejunal feeding with EF or PIEF. RESULTS: The secretin-stimulation test demonstrated significant pancreatic reserve in all patients. There was a mild increase in pancreatic exocrine secretion with jejunal feeding with EF and PIEF compared with baseline and with dextrose. There was increased bicarbonate secretion with EF compared with PIEF, but there were no other significant differences in pancreatic exocrine function. CONCLUSIONS: In this model of partial pancreatectomy, there was no significant difference in pancreatic exocrine output when use of an EF was compared with use of a PIEF for jejunal feeding. Further clinical studies are needed to determine the potential role of PIEF in pancreatic disease.

Clinically significant gastrointestinal bleeding in critically ill patients in an era of prophylaxis.

OBJECTIVE: Clinical studies examining stress-related gastrointestinal bleeding in critically ill patients vary in their clinical definitions and assessment of clinical significance. Although there is evidence that routine prophylaxis decreases stress-related gastrointestinal bleeding, recent studies indicate a decreasing incidence, independent of the use of prophylactic medications. The purpose of this study was to determine the incidence of and risk factors for clinically significant, endoscopically proven gastrointestinal bleeding in critically ill patients. METHODS: A database (prospectively collected data) of 8338 patients admitted to the surgical and medical intensive care units at major tertiary care center from July 1988 to April 1995 was examined. All patients with significant upper gastrointestinal bleeding as defined by a drop in hemoglobin of >20 g/L and endoscopic evidence of an upper GI tract source were identified. Risk factors for GI bleeding from stress ulceration were compared in bleeding and nonbleeding patients. A case-control study analyzing risk factors for bleeding in the abdominal aortic aneurysm subgroup was performed. RESULTS: After exclusion criteria, 12/7231 (0.17%) patients had clinically significant, endoscopically proven bleeding. Significant risk factors included age, septic shock, abdominal aortic aneurysm repair, and nutritional support. Intensive care unit stay was prolonged in patients with stress-related bleeding. There was no difference in incidence of hypotension, clamp time, APACHE score, or operating room time in patients with abdominal aortic aneurysm repair as compared with controls. CONCLUSIONS: In an intensive care unit where stress prophylaxis is widely used, clinically important gastrointestinal bleeding is uncommon. Further study is needed to define the optimal prophylaxis regimen and the role for its selective use in high-risk patients.

Chronic hyperlipasemia caused by sarcoidosis.

A chronically elevated lipase is a rare biochemical finding and has only previously been described in patients with malignancy and macrolipasemia. We report a case of chronic hyperlipasemia caused by sarcoidosis. The literature on pancreatic sarcoidosis is reviewed and the significance of lipase isoforms is discussed. Sarcoidosis needs to be considered in patients presenting with chronic hyperlipasemia.

The validity and reproducibility of clinical assessment of nutritional status in the elderly.

Malnutrition is an important predictor of morbidity and mortality. In the non-elderly, a subjective global assessment (SGA) has been developed. It has a high inter-rater agreement, correlates with other measures of nutritional status, and predicts subsequent morbidity. The purpose of this study was to determine the validity and reproducibility of the SGA in a group of patients older than 70 y of age. Consecutive patients from four geriatric/rehabilitation units were considered for the study. Each patient underwent independent nutritional assessments by a geriatrician and senior medical resident. At the completion of the assessment, skinfold caliper measurements were obtained and the patient reclassified according to the results, which were then compared with objective measures of nutritional status. Six-month follow-up was obtained on all patients. The agreement between the two clinicians was 0.48 +/- 0.17 (unweighted kappa), which represents moderate agreement and is less than the reported agreement in nonelderly subjects. Skin calipers improved the agreement between clinicians but did not improve the correlation with other nutritional markers or prediction of morbidity and mortality. There was a correlation between a patient's severely malnourished state and mortality. In addition, patients with a body mass index (BMI) of <75% or >150% age/sex standardized norms had an increased mortality. The SGA is a reproducible and valid tool for determining nutritional status in the elderly. The reproducibility is less than in the nonelderly, which may relate to changes in body composition or ability to obtain an accurate nutritional history.