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The double burden of malnutrition in Association of South East Asian Nations (ASEAN) countries: a comprehensive review of the literature

Background and Objectives: The double burden of malnutrition (DBM) - a combination of undernutrition and overnutrition - is a problem faced by many countries. This study aimed to comprehensively review the DBM in ASEAN (Association of South East Asian Nations) countries, including levels (population [including country, city, or any community], household, or individual), types (the type of undernutrition and overweight), and prevalence. Methods and Study Design: Data were sourced from four electronic databases, Medline via OvidSP, Scopus, Global Health via OvidSP and Web of Science, from January 1990 until May 2017. We only included studies that reported prevalence of DBM, were published in English language peer-reviewed journals and were available in full text. Studies were formally assessed against a published critical appraisal tool to produce a robust narrative review. Results: We included 48 studies in the review from eight countries. No study was found from Singapore or Brunei Darussalam. Most studies were from Indonesia and there was only one study from Lao PDR. There were a range of criteria for anthropometry used in these studies, hence comparison is impossible. DBM happened at community, household, and individual levels, with different types of undernutrition (stunting/ underweight/wasting/thinness) in combination with overweight/obesity. At the household level, DBM ranged from 5.0% in Vietnam to 30.6% in Indonesia. Conclusions: ASEAN countries may need to strengthen surveillance using WHO standards to improve the comparability of data, further develop strategies to address under- or overweight issues and investigate potential ＂double-duty actions＂ as suggested by the World Health Organization.

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Development of a screening tool to detect nutrition risk in patients with inflammatory bowel disease

Background and Objectives: Malnutrition is a known complication of Inflammatory Bowel Disease (IBD). We assessed a known screening tool, as well as developed and validated a novel screening tool, to detect nutrition risk in outpatients with IBD. Methods and Study Design: The Saskatchewan IBD-Nutrition Risk (SaskIBD-NR Tool) was developed and administered alongside the Malnutrition Universal Screening Tool (MUST). Nutrition risk was confirmed by the IBD dietitian (RD) and gastroenterologist (GI). Agreement between screening tools and RD/GI assessment was computed using Cohen’s kappa. Results: Of the 110 patients screened, 75 (68.2%) patients had Crohn’s Disease and 35 (31.8%) ulcerative colitis. Mean BMI was 26.4 kg/m^2 (SD=5.8). RD/GI assessment identified 23 patients (20.9%) at nutrition risk. The SaskIBD-NR tool classified 21 (19.1%) at some nutrition risk, while MUST classified 17 (15.5%). The SaskIBD-NR tool had significant agreement with the RD/GI assessment (k 0.83, p＜0.001), while MUST showed a lack of agreement (k 0.15, p=0.12). The SaskIBD-NR had better sensitivity (82.6% vs 26.1%), specificity (97.7% vs 87.4%), positive predictive value (90.5% vs 35.3%), and negative predictive value (95.5% vs 81.7%) than the MUST. Conclusion: The SaskIBD-NR, which assesses GI symptoms, food restriction, and weight loss, adequately detects nutrition risk in IBD patients. Broader validation is required.

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Accuracy of basal metabolic rate estimated by predictive equations in Japanese with type 2 diabetes

Background and Objectives: Estimation of energy demand using basal metabolic rate (BMR) is a rational approach for optimizing glycemic control and weight management in patients with type 2 diabetes mellitus (T2DM). Here, we assessed the accuracy of predictive equations in estimating BMR in Japanese patients with T2DM. Methods and Study Design: BMR was measured indirectly (BMR_m) with a portable gas analyzer in the fasting state in 69 Japanese patients with T2DM. BMR was estimated using the Harris-Benedict equation (BMR_(hb)) and Ganpule equation (BMR_g). An original predictive equation (BMR_(dm)) was formulated by stepwise multiple regression analysis using subject age, lean soft tissue mass, fat mass and bone mineral content. Mean differences and 95% limits of agreement between measured and three estimated BMRs were evaluated by Bland-Altman plots. In addition, subjects were divided into three BMI groups (normal, BMI ＜25; overweight, BMI ≥25; obese, BMI ≥30), and the influence of BMI on the error size between measured and estimated BMRs was assessed. Results: Between BMR_m and the three estimated BMRs (BMR_(hb), BMR_g, and BMR_(dm)), there were small systematic errors with large random errors (mean difference±2SD; -32±365 kcal，26±405 kcal, and -1.6±349 kcal, respectively) and significant proportional errors (r=0.42, 0.44, and 0.30, respectively). BMI subgroup analysis revealed that the obese group showed larger random errors and significant proportional errors compared to the overweight and normal weight groups. Conclusion: Predictive equations provide unacceptably inaccurate estimates of BMR in Japanese patients with T2DM, particularly in obese individuals.

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Risk factors for parenteral nutrition-dependence and mortality with the short bowel syndrome: a 10-year retrospective study in Thailand

Background and Objectives: Short bowel syndrome (SBS) is a rare and life-threatening disease. Few studies have investigated risk factors for parenteral nutrition (PN)-dependence and death in SBS. Accordingly, the aim of this study was to investigate the risk factors for PN-dependence and long-term mortality in SBS. Methods and Study Design: This retrospective study reviewed and evaluated children and adults who were diagnosed with SBS at King Chulalongkorn Memorial Hospital from October 2005 to January 2015. Age, causes of SBS, length of remnant bowel, type of anastomosis, types of nutrition support, SBS-associated complications, PN-dependence rate, duration of PN-dependence, mortality rate, and causes of death were evaluated. Results: Twenty-two adults and 19 children were reviewed. The median follow-up time was 48 months. At the end of follow-up, PN-dependence rate was 51.2%. The residual colon ≥50% group had a significantly lower PN-dependence rate, with a hazard ratio of 0.36 (95% CI: 0.14-0.93; p=0.03). The most frequent cause of death was infection, with the highest percentage of mortality occurring within the first 2 years after surgery. The mortality rate was 53.8% and the residual colon ≥50% group had a significantly lower mortality rate, with a hazard ratio of 0.36 (95% CI: 0.14- 0.88; p=0.03). Conclusions: PN-dependence and death occurred in about half of all patients. Residual colon ≥50% was significantly associated with lower death rate and PN-dependence. The crucial role of colon in continuity as a protective factor should be investigated further in prospective studies.

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Determinants and nutritional assessment value of hand grip strength in patients hospitalized with cancer

Background and Objectives: Hand grip strength (HGS) has emerged as a predictor of the nutritional status. However, many factors may modify the malnutrition-HGS association. This study explored the nutritional assessment value and determinants of HGS in patients hospitalized with cancer. Methods and Study Design: In this multicenter, retrospective, observational study (11,314 patients), the Receiver operator characteristic curve was used to observe HGS and nutritional status sensitivity/specificity. Sex; age; height; weight; mid-upper arm circumference (MAMC); Patient-Generated Subjective Global Assessment (PG-SGA) score; Karnofsky score; physical function (PF) domain; cognitive function (CF) domain; global health and quality of life (QL) domain of EORTC QLQ-C30 (a quality of life instrument designed by the European Organization for Research and Treatment of Cancer); and albumin, prealbumin, and hemoglobin levels were included in a Stepwise analysis model to identify the factors influencing HGS. Results: HGS showed a very low diagnostic value and accuracy for identifying severe malnourishment (area under the curve, 0.615-0.640; p＜0.01). HGS positively correlated with sex; height; weight; MAMC; Karnofsky score; QL, PF, and CF domains; and hemoglobin and prealbumin levels (Beta= 0.02-0.42, p≤0.05), and negatively with age (Beta=−0.19, p＜0.01). However, the PG-SGA score was excluded because of its very limited contribution to HGS variability. Conclusions: HGS is a mutifactorial index. The use of HGS cutoff values to identify malnutrition is markedly challenging. Thus, HGS may be of limited use as a predictor of nutritional status.

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The effects of Melissa officinalis (lemon balm) in chronic stable angina on serum biomarkers of oxidative stress, inflammation and lipid profile

Background and Objectives: Coronary artery disease (CAD) is a major cause of death worldwide. Chronic stable angina (CSA) is the primary sign of CAD. Oxidative stress and inflammation play a substantial role in pathogenesis and progression of CAD. The aim of this study was to investigate the effects of oral administration of powdered Melissa officinalis (MO) on biomarkers of oxidative stress, inflammation, and lipid profile in patients with CSA. Methods and Study Design: A randomized, double-blind, placebo-controlled clinical trial was performed in 80 patients with CSA. The subjects were randomly assigned to obtaineither oral MO 3 g/d (n=40) or placebo (n=40) for eight weeks. Anthropometric indices, biomarkers of oxidative stress, inflammation, and lipid profile were evaluated at baseline and post-intervention. Results: The mean serum concentrations of triglycerides, total-cholesterol, LDL-cholesterol, and malondialdehyde (MDA), and high sensitive C-Reactive Protein (hs-CRP) were lower in the intervention group compared with placebo (p＜0.01) post intervention. Moreover, the mean serum concentration of paraxonase 1 (PNO1) and HDL-c were higher (p＜0.001) in the intervention group compared with the control group. Conclusion: Oral MO supplementation improves the lipid profile, MDA, hs-CRP, and PNO1 in patients with CSA.

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Effect of ascorbic acid rich, micro-nutrient fortified supplement on the iron bioavailability of ferric pyrophosphate from a milk based beverage in Indian school children

Background and Objectives: Nutritional anemia is a significant public health issue with 50-80% prevalence in Indian children. Fortification of food, specifically milk, with iron is a potential approach to increase dietary iron intake. Ferric pyrophosphate [Fe_4(P_2O_7)_3] is organoleptically neutral and is less soluble in acid medium and, further, has low bioavailability in milk. However, since ascorbic acid is a potent enhancer of iron absorption, the coadministration of ascorbic acid with Fe_4(P_2O_7)-3 might enhance the absorption of iron. We evaluated the effect of ascorbic acid on iron absorption from a Fe_4(P_2O_7)_3 and an ascorbic acid fortified milk beverage with respect to milk fortified with Fe_4(P_2O_7)_3 alone. Methods and Study Design: A double-blind, two-way crossover, randomized study was conducted in 25 mildly anemic children. The test group received milk fortified with beverage powder containing 7 mg isotopically labeled iron (^(57)Fe/^(58)Fe) as Fe_4(P_2O_7)_3, equimolar proportions of ascorbic acid and 200 mg of calcium whereas control group received milk fortified with energy, calcium and iron equivalent beverage powder. Fractional iron absorption was measured by erythrocyte incorporation of stable isotopes of iron (^(57)Fe/^(58)Fe) in both the groups. Results: The fractional iron absorption from the control drink was 0.80% (95% CI: 0.57, 1.12). Fortifying the milk with an equimolar amount of ascorbic acid increased the fractional iron absorption almost 2-fold to 1.58% (95% CI: 1.13, 2.22). Conclusions: The presence of ascorbic acid in an equimolar ratio with that of iron from Fe_4(P_2O_7)_3 salt in milk as a fortificant enhanced iron absorption when compared to milk fortified with only Fe_4(P_2O_7)_3.

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Supplementation with trans fatty acid at 1% energy did not increase serum cholesterol irrespective of the obesity-related genotypes in healthy adult Japanese

Background and Objectives: The excessive intake of trans fatty acids increases serum low-density lipoprotein-cholesterol and reduces high-density lipoprotein-cholesterol. We studied the effects of 1% energy trans fatty acid supplementation on serum lipid concentrations in healthy adult Japanese with different obesity-related gene polymorphisms. Methods and Study Design: A randomized, double-blind, parallel trial was conducted in 53 healthy adults. The volunteers consumed one cookie containing either 1% energy or ＜0.01% energy (control) of trans fatty acids every day for 4 weeks, and a blood sample was then obtained after overnight fasting. The single nucleotide polymorphisms of the fat mass- and obesity-associated gene rs9939609 and beta-3 adrenergic receptor rs4994 were genotyped. Results: The mean trans fatty acid intake of the control and trans fatty acid groups corresponded to 0.28% and 1.31 % energy, respectively. There were no significant differences in serum cholesterol (total, low-density lipoprotein and high-density lipoprotein) or triacylglycerol between the control and trans fatty acid groups. The responses of serum cholesterol, triacylglycerol, glucose, insulin and hemoglobinA1c were also independent of the fat mass- and obesity-associated gene and beta-3 adrenergic receptor gene variants. Conclusions: Our findings indicate that supplementation with 1% energy trans fatty acids has little effect on serum cholesterol in healthy adult Japanese, regardless of genotype of fat mass- and obesity-associated gene or beta-3 adrenergic receptor. More systematic studies, with respect to dietary trans fatty acid intakes above those used here, may be warranted to determine the tolerable upper level of dietary trans fatty acid.

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Effect of a daily snack containing green leafy vegetables on women’s fatty acid status: a randomized controlled trial in Mumbai, India

Background and Objectives: There are few data on the fatty acid status of non-pregnant Indian women. Our objective was to investigate the effect of a snack containing green leafy vegetables (GLVs) on women’s erythrocyte long chain polyunsaturated fatty acid status (LCPUFA). Methods and Study Design: Non-pregnant women (n=222) aged 14-35 years from Mumbai slums were randomized to consume a snack containing GLVs, fruit and milk (treatment) or a control snack containing foods of low micronutrient content such as potato and onion, daily under observation. One treatment snack contained a mean (SD) of 54.1 (33.7) mg alpha-linolenic acid (ALA) and one control snack contained 4.1 (3.4) mg ALA. Blood was collected at baseline (0 weeks) and after 12 weeks of supplementation. Erythrocyte fatty acids were analyzed using gas chromatography and expressed as g/100g fatty acids. Plasma malondialdehyde, homocysteine, and erythrocyte superoxide dismutase and glutathione peroxidase were measured. The effect of the treatment on 12 week LCPUFA was assessed using ANCOVA models. Results: Median (IQR) erythrocyte DHA in the treatment group increased from 1.50 (1.11, 2.03) at baseline to 1.86 (1.50, 2.43) (p＜0.001) at 12 weeks, and fell in controls from 1.78 (1.37, 2.32) to 1.60 (1.32, 2.04) (p＜0.001). The total n-3 fatty acids increased in the treatment group. There was no effect on malondialdehyde and antioxidant enzyme levels. Plasma homocysteine at 0 and 12 weeks was inversely associated with erythrocyte DHA at 12 weeks. Conclusion: Daily consumption of a snack containing GLV improved women’s erythrocyte DHA levels without increasing oxidative stress.

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Comparison of effectiveness, safety, and costs of standardized and customized parenteral nutrition support among gastric cancer patients after gastrectomy: a retrospective cohort study

Background and Objectives: To compare the effectiveness, safety, and costs of commercial standardized multi-chamber bag and customized compounded total parenteral nutrition (TPN) among gastric cancer patients after gastrectomy. Methods and Study Design: A retrospective cohort study was conducted among 64 gastric cancer patients who underwent gastrectomy from 2014 to 2016 in a tertiary teaching hospital in Beijing, China. Patients were categorized into standardized (s-TPN) and customized TPN (c-TPN) groups based on their TPN order after gastrectomy. Patients were followed up until discharge. The effectiveness measures (body mass index (BMI) and albumin) and safety measures (liver and renal functions and electrolytes) were compared before TPN started and after TPN finished within and between the two groups. The length of hospital stay and costs were compared between the two groups. Results: There were no significant differences between the two groups in BMI preservation, metabolic complications, the length of hospital stay and costs, except that both total bilirubin (Tbil) and direct bilirubin (Dbil) were significantly higher in the s-TPN group than c-TPN (p＜0.05). Conclusions: There were no significant differences in effectiveness and safety measures, the length of hospital stay and costs between s- TPN and c-TPN groups, except that s-TPN group was more likely to lead to parenteral nutrition-associated liver disease (PNALD). More studies are needed to confirm the findings of this study in other healthcare settings and study populations.