Identifying nutritional deficits and implementing appropriate interventions in patients requiring vascular surgery is challenging due to the paucity of appropriate screening and assessment tools in this group. This retrospective study aimed to determine the validity of the Global Leadership Initiative on Malnutrition (GLIM) in identifying protein–energy malnutrition (PEM) in inpatients admitted to a vascular surgery unit, using the PG-SGA as the comparator. Diagnostic accuracy and consistency were determined between the GLIM and the Patient-Generated Subjective Global Assessment (PG-SGA) global rating. The GLIM determination was made retrospectively using the relevant parameters collected at baseline in the original study. Two hundred and twenty-four (70·1 % male) participants were included. The prevalence of PEM was 28·6 % on GLIM and 17 % via the PG-SGA. Compared with the PG-SGA, the GLIM achieved sensitivity of 73·7 % and specificity of 80·6 %; however positive predictive value was 43·7 % indicating that the GLIM over-diagnosed malnutrition compared with the PG-SGA. Kappa reached 0·427 indicating moderate diagnostic consistency. Due to the absence of an ideal instrument and the complexity of malnutrition often seen in this group which extends beyond PEM to significant micronutrient deficiencies, further work is required to determine the most appropriate instrument in this patient group, and how micronutrient status can also be included in the overall assessment given the critical role of micronutrients in this group.

Protein is important for growth, maintenance and protection of the body. Both adequacy of protein quantity and protein quality in the diet are important to guarantee obtaining all the essential amino acids. Protein–energy malnutrition is widely present in developing countries such as Nigeria and might result in stunting and wasting. Needs for protein differ depending on age and physiological status and are higher during growth, pregnancy and lactation. The present review assessed protein quantity and quality in diets of Nigerian infants, children, adolescents, and pregnant and lactating women. Literature reviews and calculations were performed to assess adequacy of Nigerian protein intake and to examine the Nigerian diet. The digestible indispensable amino acid score was used to calculate protein quality of nine Nigerian staple foods and of a mixture of foods. The Nigerian population had mostly adequate protein intake when compared with the most recent protein recommendations by the FAO (2013) and WHO/FAO/UNU (2007). An important exception was the protein intake of adolescent girls and pregnant and lactating women. Most of the assessed Nigerian plant-based staple foods were of low protein quality and predominantly lacked the amino acid lysine. The addition of animal-source foods can bridge the protein quality gap created by predominance of plant-based foods in the Nigerian diet. The methodology of this review can be applied to other low- and middle-income countries where diets are often plant-based and lack variety, which might influence protein intake adequacy.

The declining inflammatory immune competence of acute (i.e. wasting) pre-pubescent protein–energy malnutrition has been regarded as reflecting an unregulated immunological disintegration. Recent evidence, however, suggests that malnutrition stimulates a regulated immunological reconfiguration to achieve a non-inflammatory form of competence, perhaps offering protection against autoimmune reactions – the ‘Tolerance Model’. Our objective was to determine the influence of acute pre-pubescent malnutrition on the expression of genes critical to tolerogenic regulation. Male and female C57BL/6J mice, initially 19 d old, consumed a complete purified diet either ad libitum (age-matched controls) or in restricted daily quantities (mimicking marasmus), or consumed an isoenergetic low-protein diet ad libitum (mimicking incipient kwashiorkor) for 14 d (six animals per dietary group). Gene expression in the spleen, typically an inflammatory organ, and in the small intestine, a site designed for non-inflammatory defence, was assessed by real-time quantitative RT-PCR, and normalised to β-actin. In the spleen of the malnourished groups, both IL-10 and transforming growth factor-β1 mRNA expression increased compared with controls (P < 0·05), whereas mRNA expression of IL-12p40 decreased (P < 0·05). Conversely, malnutrition exerted no influence on the expression of mRNA for these cytokines in the small intestine (P>0·05). Moreover, forkhead box P3 mRNA expression, indicative of cell-based tolerogenic potential, was sustained in both the spleen and intestine of the malnourished groups (P>0·05). Thus, despite limited supplies of energy and substrates, the spleen shifted towards a non-inflammatory character and the intestine was sustained in this mode in advanced pre-pubescent weight loss. These findings provide the first support for the Tolerance Model at the level of mRNA transcript expression.

Clinical response to medication can differ between patients. Among the known sources of variability is an individual's nutrition status. This review defines some pharmacokinetic terms, provides relevant body size metrics and describes the physiologic influences of protein–energy malnutrition and obesity on drug disposition. Weight-based drug dosing, which presumes a healthy BMI, can be problematic in the protein–energy malnourished or obese patient. The use of total body weight, lean body weight, or an adjusted body weight depends on the drug and how it is differently handled in malnutrition or obesity. Most of the recognized influences are seen in drug distribution and drug elimination as a result of altered body composition and function. Distribution characteristics of each drug are determined by several drug-related factors (e.g. tissue affinity) in combination with body-related factors (e.g. composition). Drug elimination occurs through metabolic and excretory pathways that can also vary with body composition. The current data are limited to select drugs that have been reported in small studies or case reports. In the meantime, a rational approach to evaluate the potential influences of malnutrition and obesity can be used clinically based on available information. Antimicrobials are discussed as a useful example of this approach. Further advancement in this field would require collaboration between experts in body composition and those in drug disposition. Until more data are available, routine monitoring by the clinician of the protein–energy malnourished or obese patient receiving weight-based drug regimens is necessary.

Plasma transforming growth factor (TGF)-β levels are high in the advanced stages of acute (wasting) pre-pubescent deficits of protein and energy. Consequently, this potently anti-inflammatory cytokine may help to sustain the depression of inflammatory immune competence in acute malnutrition. Our objective was to determine if plasma TGF-β levels rise during the early stages of acute malnutrition and, secondarily, to confirm the elevation reported previously in advanced weight loss. In two experiments, male and female C57BL/6J mice, initially 19 d old, consumed ad libitum a complete purified diet (group C), or in restricted daily quantities (group R) or had free access to an isoenergetic low-protein diet (group LP). TGF-β bioactivity in platelet-poor plasma was determined via inhibition of Mv1Lu mink lung cell proliferation after 3 d (Expt 1, early stage) or 14 d (Expt 2, advanced stage) of dietary intervention. At 3 d, mean plasma TGF-β bioactivities were 802 (C), 2952 (R) and 4678 (LP) pg/ml, and after 14 d mean bioactivities were 1786 (C), 5360 (R) and 5735 (LP) pg/ml. At both time points, the malnourished groups differed from age-matched controls (P ≤ 0·05). Thus, metabolically distinct weanling systems mimicking paediatric marasmus (group R) and kwashiorkor (group LP) exhibit an early rise in blood TGF-β concentration, and this cytokine joins corticosterone and IL-10 as a third anti-inflammatory hormone temporally positioned to contribute to the initiation (and maintenance) of malnutrition-associated immune depression. This investigation contributes new insight into the active anti-inflammatory form of immune competence that appears to prevail in acute pre-pubescent malnutrition.

The main objective of the present study was to determine the influence of acute deficits of protein and energy on the blood serum level of interferon-γ, a signature type 1 polarising inflammatory cytokine. In two 14 d experiments, male and female C57BL/6J mice, initial age 19 d, consumed a complete purified diet ad libitum or in restricted daily quantities, or had free access to an isoenergetic purified low-protein diet. A zero-time control group (age 19 d) was included in the second experiment. Serum interferon-γ was assessed in both experiments by sandwich ELISA and, in the second experiment, also by a bioassay based on inhibition of proliferation by WEHI-279 B lymphoma cells. The immunoassay detected interferon-γ inconsistently in all groups (range 0–14 pg/ml; detection limits 1·5 and 0·7 pg/ml in experiments 1 and 2, respectively). By contrast, interferon-γ bioactivity was found in all animals of each group (means 339, 499, 124 and 200 pg/ml in zero-time controls, age-matched controls, low-protein and restricted intake groups, respectively; detection limit, 12 pg/ml), and the mean serum bioactivity of each malnourished group was low compared with the age-matched control (P ≤ 0·05). The present study defines the physiological serum interferon-γ bioactivity of the adolescent mouse. Moreover, to the extent achievable by way of the blood, the results reflect the influence of metabolically diverse forms of acute malnutrition on the polarising type 1 cytokine profile within lymphoid microenvironments wherein immune responses arise. Therefore, the results suggest a mechanism underlying the cell-mediated inflammatory incompetence that characterises acute, prepubescent malnutrition.

Protein–energy malnutrition and nosocomial infection (NI) are frequent in elderly patients, and a causal link between the two has often been suggested. The aim of the present study was to identify the nutritional parameters predictive of NI in elderly patients. We assessed on admission 101 patients (sixty-six women, thirty-five men, aged over 65 years) admitted to an acute care of the elderly department. Sarcopenia was detected by dual-energy X-ray absorptiometry, with appendicular skeletal muscle mass expressed with respect to body area. Weight, BMI, albuminaemia, serum transthyretin and C-reactive protein values were also determined on admission, and known risk factors, such as functional dependence and invasive biomedical material, were also evaluated. After up to 3 weeks of hospitalisation, patients were classified according to whether they had developed an NI. After 3 weeks of hospitalisation, we found that twenty-nine patients had suffered an NI, occurring after a mean of 16·1 d. Patients who were sarcopenic on admission had a significantly higher risk of contracting an NI (relative risk 2·1, 95 % CI 1·1, 3·8). None of the other morphometric or biological parameters differed significantly between the two groups of patients on admission. Patients who experienced an NI were also more likely, on admission, to have a medical device (P=0·02 to P=0·001 depending on the device), to have swallowing problems (P=0·002) or to have restricted autonomy (P<0·01). Sarcopenia on admission to an acute care of the elderly unit, as measured by X-ray absorptiometry, was therefore associated with a doubled risk of NI during the first 3 weeks of hospitalisation.

The aim of the present prospective study was to determine if malnutrition, measured using a simple validated score, is an independent risk factor for nosocomial infections (NI) in non-selected hospital in-patients. Between 29 and 31 May 2001, a survey on the prevalence of NI was conducted on all 1637 in-patients (61 (sd 25) years old) in a French university hospital as part of a national survey. Actual and usual body weights were recorded in all in-patients, and serum albumin levels were measured on all blood samples taken during the week before the study. Nutritional status was evaluated by using the nutritional risk index (NRI). Albumin values were obtained in 1084 patients, and complete weight information was obtained in 911. Therefore, NRI was calculated in 630 patients (61 (sd 20) years old): 427 (67·8%) were malnourished. NI prevalence was 8·7%: 4·4% in non-malnourished patients, 7·6% in moderately malnourished patients and 14·6% in severely malnourished patients. In univariate analysis, the odds ratios for NI were 1·46 (95% CI 1·2, 2·1) in moderately malnourished patients and 4·8 (95% CI 4·6, 6·4) in severely malnourished patients. In multivariate analysis, age, immunodeficiency and NRI class influenced NI risk. Vascular and urinary catheters, and surgical intervention, were the extrinsic factors associated with NI, with odds ratios ranging from 2·0 (95% CI 1·8, 2·6) for vascular catheters to 10·8 (95% CI 8·8, 12·6) for association of the three factors. In conclusion, in non-selected hospitalized patients, malnutrition assessed with a simple and objective marker is an independent risk factor for NI. An early screening for malnutrition may therefore be helpful to reduce the high prevalence of NI.