How to Order the Diet


The diet uses the 1800 – two,000 nutritionist’s calorie



level because the normal reference level for adults. Specific calorie levels may have to be adjusted supported age, gender and physical activity.

How to Order the Diet

Order as “Regular Diet,” indicating any special directions.

Planning the Diet

The Dietary tips for Americans and portion sizes use the USDA Food Guide and also the DASH (Dietary Approaches to Stopping Hypertension). The Dietary Guidelines ar supposed for all Americans, healthy and people at magnified risk of chronic sickness. However,

modifications is also needed whereas treating patients World Health Organization ar unwell, because the main goal is to encourage food

intake, which often needs “comfort foods,” like soup, sandwiches, and alternative foods the patient is accustomed to. thereupon thought, the amount of servings of foods from every food cluster could dissent

from the recommendations. However, the meal can still be planned to satisfy the DRIs whenever doable.

Dietary Guidelinesfor Americans encompasses 2 overarching ideas :

Maintain calorie balance over time to realize and sustain a healthy weight

concentrate on intense nutrient-dense foods and beverages inside basic food teams whereas dominant

calorie and atomic number 11 intake

Recommended healthy uptake pattern:




Daily atomic number 11 intake to but two,300 mg and any scale back intake to one,500 mg among one that ar

51 and older and any age World Health Organization ar African yank or have high blood pressure polygenic disease, or chronic urinary organ

disease. At constant time, consume foods with additional K, dietary fiber, atomic number 20 and cholecarciferol.

Increase daily intake of fruits and vegetables, whole grains, and nonfat or milk and milk product.

Consume but ten % of calories from saturated fatty acids by substitution with monounsaturated

and unsaturated fatty acids. Oils ought to replace solid fats once doable.

Keep trans fat as low as doable.

scale back the intake of calories from solid fats and extra sugars.

Limit consumption of foods that contain refined grains, particularly refined grain foods that contain solid

fats, extra sugars, and sodium.

If you drink alcoholic beverages, do thus sparsely, for under adults of legal status.

Keep food safe to eat.




NOTE: A Tolerable higher Intake Level (UL) is that the highest level of daily nutrient intake that’s doubtless to cause no risk of adverse effects to most people within the general population.

Unless otherwise such, the UL represents total

because of lack of appropriate knowledge, ULs couldn’t be established for antihemorrhagic factor, thiamin, riboflavin, B-complex vitamin, vitamin B complex, biotin, carotenoids.


within the absence of ULs, additional caution could also be


warranted in overwhelming levels on top of suggested intakes.


Members of the overall population ought to be suggested to not habitually exceed the UL.


The UL isn’t meant to use to people UN agency area unit treated with the nutrient underneath


medical superintendence or to people with predisposing conditions that modify their sensitivity to the nutrient


a though the UL wasn’t determined for arsenic, there’s no justification for adding arsenic to food or supplements.


Additional foods and supplements area unit superimposed to meals or between meals to extend macromolecule and energy intake




A high-protein, high-calorie diet is served once macromolecule and energy necessities area unit enlarged by stress,

protein loss (protein losing disease, nephrotic syndrome), and katabolism. This diet could also be indicated in

patients with:

protein-energy deficiency disease

failure to thrive



monogenic disease

human immunological disorder virus (HIV)/acquired immunological disorder syndrome (AIDS)

chronic duct diseases

This diet may additionally be indicated in preparation for surgery. a rise in energy is needed to push the

efficient utilization of proteins for constructive metabolism.

Nutritional Adequacy

The diet are often planned to fulfill the Dietary Reference Intakes (DRIs)

How to Order the Diet

Order as “High-Protein, High-Calorie Diet.” The specialist determines a target level of macromolecule and energy to

meet individual wants supported tips as expressed in Section II: Estimation of macromolecule necessities.

Planning the Diet

The diet is planned as a daily Diet with addition of between-meal supplements that increase energy intake

by a minimum of five hundred kcal and macromolecule intake by twenty five g for adults. samples of high-protein, high-energy supplements

are milk shakes, eggnogs, puddings, custards, and business supplements.

For youngsters, the diet usually ought to offer one hundred twenty to one hundred and fiftieth of the Dietary Reference Intakes (DRIs) for

energy and macromolecule. the particular amounts of energy and macromolecule provided can rely on the child’s or

adolescent’s age, height, weight, medical standing, and nutrition goals






NOTE: A Tolerable higher Intake Level (UL) is that the highest level of daily nutrient intake that’s probably to create no risk of adverse effects to the majority people within the general population. Unless otherwise specific, the UL represents

total intake from food, water, and supplements. because of lack of appropriate knowledge, ULs couldn’t be established for naphthoquinone, thiamin, riboflavin, B-complex vitamin, vitamin B complex, biotin, carotenoids. within the absence of ULs, further caution could

be secure in overwhelming levels on top of counseled intakes. Members of the overall population ought to be suggested to not habitually exceed the UL. The UL isn’t meant to use to people WHO area unit treated with the nutrient

under medical supervising or to people with predisposing conditions that modify their sensitivity to the nutrient.

aAs preformed fat-soluble vitamin solely.

bAs α-tocopherol; applies to any type of type of.

dThe ULs for tocopherol, niacin, and folic acid apply to artificial forms obtained from supplements, fortified foods, or a mixture of the 2.

db-Carotene supplements area unit suggested solely to function a provitamin A supply for people in danger of fat-soluble vitamin deficiency.

eND = Not determinable because of lack of knowledge of adverse effects during this people and concern with relation to lack of ability to handle excess amounts. supply of intake ought to be from food solely to stop

high levels of intake

NUTRITION MANAGEMENT throughout physiological state AND LACTATION

Diets for pregnant or wet ladies embrace further servings of food from the Regular Diet to satisfy the Diets for pregnant or wet ladies embrace further servings of food from the Regular Diet to satisfy the

increased demand for nutrients throughout physiological state and lactation.

Nutritional Adequacy

The food patterns can meet the Dietary Reference Intakes (DRIs) for physiological state and lactation,  Statement on organic process Adequacy, apart from the iron necessities within the second and third

trimesters of physiological state. Factors which will increase organic process necessities higher than the calculable demands of

pregnancy include: poor organic process status; young maternal age; multiple physiological state; closely spaced births;

breast-feeding throughout pregnancy; continuing high level of physical activity; bound malady states; and therefore the use

of cigarettes, alcohol, and legal or extralegal medication. Dietary intake of iron, folate, zinc, protein, and atomic number 20 ought to

be fastidiously assessed for adequacy . Supplementation is even once proof suggests that the

inadequate intake of specific nutrients will increase the danger of AN adverse impact on the mother, fetus, or

pregnancy outcome. Vegetarians WHO exclude all animal merchandise would like a pair of mg of cyanocobalamin daily.

How to Order the Diet

Order as “Regular Diet – Pregnancy” or “Regular Diet – Lactation.” Any special directions ought to be

indicated within the diet order.



Planning the Diet

Daily Food cluster pointers

No. of Servings

Food cluster Pregnant ladies wet ladies

Grains, Breads, and Cereals 9 six to eleven

Fruits 3 2 to four

Vegetables four 3 to 5

Low-fat Meat, Poultry, Fish, and Eggs 2 or additional (6 oz) 2 or additional (7-8 oz)

Low-fat Milk, Yogurt, Cheese 3 or four four or 5

Fats, Oils, and Sweets pro re nata to supply energy

Specific Nutrient necessities throughout physiological state

Weight gain: The National Academy of Sciences’ Food and Nutrition Board has explicit that the optimum weight gain

during physiological state depends on the mother’s weight at the start of physiological state . The firing range for weight

gain is related to a mature, healthy baby, deliberation a mean of three.1 to 3.6 kg (6.8 to 7.9 lb) . The


optimum weight gain for a girl of traditional prepregnancy weight for her height (body mass index (BMI), 19.8 to

26 kg/m2) WHO is carrying one foetus is twenty five to thirty five lbs; but, there square measure individual variations supported

maternal measuring and ethnic tight. The pattern of weight gain is additional important than absolutely the

weight gain. the specified pattern of weight gain is just {about|some|roughly|more or less|around|or so} three to eight pound within the trimester and about one

lb/week throughout the last 2 trimesters.

The BMI, outlined as weight divided by the peak square (kg/m2), could be a higher indicator of maternal

nutritional standing than is weight alone. Recommendations for weight gain throughout physiological state ought to be

individualized in line with the prepregnancy BMI


Energy: the overall energy desires throughout maternity vary between two,200 and 2,900 kcal/day for many girls

. However, the mother’s age, prepregnancy BMI, rate of weight gain, and physiological appetency should be

considered once determinative individual desires. supported a review of proof, a median further

intake of roughly 340 to 452 kcal/day is usually recommended within the second and third trimesters . For normal

weight and overweight girls in developed countries, the extra energy would like may very well be but

300 kcal/day, particularly in inactive girls . acceptable weight gain and appetency square measure higher indicators

of energy sufficiency than the number of energy consumed . it’s been steered that a further five hundred

kcal/day for a twin maternity is else to the calculated desires. there’s no absolute recommendation within the

literature for the number of further energy required for a multiple maternity. The indication is to feature five hundred

kcal/day within the trimester as presently because the multiple maternity is diagnosed, as a result of these pregnancies

usually don’t move to term and also the goal is to maximise the first weight gain . Pregnant girls ought to

consume a spread of foods per the Dietary tips to fulfill nutrient desires and gain the

recommended amounts of weight . MyPyramid tips embody MyPyramid for Moms, that contains



food plans for pregnant girls.

Protein: The 2002 DRIs list the suggested daily allowances for supermolecule for all age teams throughout

pregnancy and lactation to be one.1 g/kg per day or a further twenty five g/day additionally to the zero.8 g/kg per day

for a nonpregnant state . On average, this recommendation equates to some seventy one g, except for girls

with larger energy desires, the supermolecule desires might have to be adjusted. For a twin maternity, a further fifty

g/day of supermolecule higher than the suggested daily allowance of zero.8 g/kg per day for a nonpregnant state is

suggested throughout the second and third trimesters . supermolecule utilization depends on energy intake.

Therefore, adequate energy intake is very important in order that supermolecule is also spared.

Vitamins and minerals: A multivitamin pill and mineral supplement is usually recommended in many circumstances

. Pregnant girls United Nations agency smoke or abuse alcohol or medicine ought to take a multivitamin pill and mineral

supplement . for ladies infected with the human immunological disorder virus, particularly girls United Nations agency receive

antiretroviral treatment, a supplement containing B-complex, vitamin E, and antioxidant could slow the

progression of sickness and cut back complications . A multivitamin pill and mineral supplement is additionally

recommended for ladies with iron deficiency anemia or poor-quality diets and girls United Nations agency consume animal

products seldom or not the least bit . B12 supplementation is usually recommended for persons United Nations agency follow a feeder

diet pattern, as well as the lacto-ovo feeder diet pattern . girls carrying 2 or a lot of fetuses also are

advised to consume a multivitamin pill and mineral supplement . further nutrients that will got to be

supplemented embody vitamin M, iron, zinc, copper, calcium, and vitamin D. The Food and Nutrition Board

recommends the utilization of supplements or fortified foods to get fascinating amounts of some nutrients, such as

iron. The Food and Nutrition Board additionally recommends four hundred g/day of artificial vitamin M from fortified foods,

supplements, or each for ladies United Nations agency try to become pregnant and 600 g/day for ladies United Nations agency square measure

pregnant .





to fulfill the DRI of twenty seven mg/day of ferric iron throughout maternity, a low-dose supplement is

recommended at the primary antepartum visit . associate degree iron supplement containing one hundred fifty mg of ferric sulphate, 300mg of metal gluconate, or a hundred mg of metal fumarate will fulfill this extra want. Iron deficiency anemia

is the most typical anemia throughout maternity. If the maternal iron stores square measure low, sixty to one hundred twenty mg of iron could

, additionally to a vitamin pill supplement containing fifteen mg of metal and a pair of mg of copper,

since iron could interfere with the absorption of metal and copper . If the laboratory values indicate

macrocytic anemia, vitamin B complex and pteroylglutamic acid levels ought to be assessed.

Zinc and copper: Iron will interfere with the absorption of different minerals. Therefore, girls World Health Organization take daily

supplements with quite thirty mg of iron ought to add fifteen mg of metal and a pair of mg of copper . These amounts of

zinc and copper square measure habitually found in prenatal vitamins.


The DRI for pteroylglutamic acid for ladies nineteen to fifty years mature is 600 g/day (7,8). This level of pteroylglutamic acid ought to be

consumed through artificial B from fortified foods or supplements or each, additionally to the intake of

folate from a varied diet . Compared to present pteroylglutamic acid found in foods, the B contained

in fortified foods and supplements is sort of doubly in addition absorbed, in order that one g from these sources is

equivalent to one.7 g of dietary pteroylglutamic acid . girls World Health Organization take B at the time of conception square measure less possible to

give birth to a toddler with exoderm defects . to make sure that blood alimentation levels square measure adequate at the

time of exoderm closure, supplementation ought to begin a minimum of one month before conception . Women

who take multivitamins containing B one to two months before conception have a reduced risk of getting a

child with orofacial clefts . analysis conjointly indicates that abnormal pteroylglutamic acid metabolism could play a task in

Down syndrome and different birth defects . girls World Health Organization have delivered associate kid with exoderm defects

may need to consume quite the suggested quantity of dietary pteroylglutamic acid equivalents . Until more

evidence is obtainable, it’s suggested that ladies older than nineteen years mature not exceed the tolerable

upper limit of one,000 g/day of pteroylglutamic acid from foods, fortified foods, and supplements . though in depth

public education regarding the importance of B has occurred within the past decade, the share of ladies

who take B remains low at close to thirty third . Dietitians ought to offer nutrition education and

counseling on the importance of B consumption, particularly for ladies World Health Organization square measure nonwhite, Hispanic,

low-income, or young or World Health Organization lack a highschool education .

Calcium: thanks to the exaggerated potency of metallic element absorption throughout maternity, metallic element needs for

pregnant girls square measure like the necessities for ladies World Health Organization don’t seem to be pregnant. A daily intake of one,000

mg is suggested for pregnant and wet girls  previouser than nineteen years (<19 years old, 1,300 mg/day)

. girls World Health Organization avoid farm product and admit calcium-fortified fruit crush or different fortified foods could

have lower intakes of D and metal than milk shoppers, thus their diets ought to be

evaluated for the adequacy of those nutrients.

Sodium: Na is needed throughout maternity for the increasing maternal tissue and fluid compartments and

to provide foetal wants. Routine Na restriction isn’t suggested .

Vitamin A: High doses of axerophthol throughout maternity have caused birth defects of the top, heart, brain, and

spinal twine. The Food and Drug Administration (FDA) and therefore the Institute of medication advocate that alimentation

A intake be restricted to the DRI of five,000 IU throughout maternity (14,15). additionally, pregnant girls ought to limit

their intake of liver and fortified cereals. The authority recommends that ladies of childbearing age opt for

fortified foods that contain axerophthol within the variety of beta carotene instead of preformed axerophthol. A high

intake of fruits and vegetables wealthy in beta carotene and different carotenoids isn’t a priority .

Fluids: Adequate fluid intake is extraordinarily vital. The suggested daily fluid intake for pregnant

women is eight to ten cups or thirty five to forty mL/kg of pregravid weight .




Fiber: consumption of fiber is very important to hurry digestion and forestall constipation and hemorrhoids. The

2002 DRI for adequate intake of total fiber is twenty eight g/day for all age teams throughout maternity .

Other Substances

Alcohol: The consumption of alcohol throughout maternity could end in foetal alcohol syndrome. Even light-weight to

moderate drinking could cause neurological abnormalities not



consumption, whereas alternative studies have found a rise in stillbirths, spontaneous abortions, and fetal

malformations in pregnant girls WHO consumed high levels of caffein (>300 to five hundred mg/day)

more recent prospective study found that craniate growth restriction occurred at caffein intakes bigger than

100 mg/day . till additional proof provides pointers for setting a particular limit on caffein intake,

women ought to be educated on the risks related to caffein consumption and also the potential have to be compelled to limit

caffeine supported predisposing risk factors .

Olestra: Studies of the fat substitute olestra conclude that pregnant or breast-feeding girls shouldn’t

consume product containing olestra. Olestra causes epithelial duct distress and symptom, which can lead

to the loss of the fat-soluble vitamins A, D, E, and K (20).

Nonnutritive Sweeteners: The Food and Drug Administration has approved seven nonnutritive sweeteners for general use:

aspartame, acesulfame-K, Nilotic Han guo extract, neotame, saccharin, sucralose, and stevia. All FDA-approved

nutritive and nonnutritive sweeteners approved to be used by the overall public, includes pregnant and fresh

women. The Food and Drug Administration and skilled communities have ended that these sweeteners area unit safe, supported studies of

the effects of those sweeteners on the craniate and also the procreative talents of females and males . Thus,

consumption of acesulfame-K, aspartame, saccharin, sucralose, stevia, Nilotic Han guo, and neotame inside the

acceptable daily intakes is safe throughout gestation . analysis continues to point that sweetening is safe

during gestation, though girls with inborn error of metabolism ought to exercise caution with this sweetener

because they have to closely monitor their intake of essential amino acid . there’s restricted proof that

saccharin will suffer the placenta which it remains in craniate tissues; so, girls ought to

moderate their intake of this sweetener . in an exceedingly study in 2010, associate association between intakes of nonnutritive

sweetened effervescent and uncarbonated soft drinks and preterm birth was found among Danish girls

. girls WHO consumed one or additional nonnutritive sweet beverage per day were considerably additional

likely to deliver preterm . The association was stronger for effervescent beverages with sweetening and

acesulfame-K compared to uncarbonated beverages. This finding has not been confirmed in alternative studies to

date .

Herbal and various therapies: only a few randomised clinical trials have examined the security and effectualness

of alternative therapies throughout gestation . many flavourer and biological science supplements area unit harmful if used

during gestation . The yank Academy of pediatric medicine recommends that pregnant girls limit their

consumption of flavourer teas. girls WHO like better to consume flavourer teas ought to limit their intake to 2 8-oz

servings per day and select flavourer teas in filtered tea luggage .

Fish: because of the high levels of mercury in sure forms of fish and mercury’s adverse effects on the craniate, the

US Department of Health and Human Services and also the U.S.A. Environmental Protection Agency recommend limiting

the type and quantity of fish consumed throughout gestation . Pregnant girls ought to avoid overwhelming shark,

swordfish, cero, or tilefish. Twelve ounces or less per week of fish and shellfish lower in mercury,

such as shrimp, canned light-weight tuna, salmon, pollock, and catfish, is safe . Consumption of albacore (“white”)

tuna ought to be restricted to six oz/week, as a result of this kind of tuna contains additional mercury than canned light-weight tuna

. If no info relating to fish caught from native water sources is accessible, pregnant girls ought to

limit their consumption of those fish to six oz/week and not consume the other fish throughout that week .

Foodborne health problem throughout gestation

Pregnant girls and their fetuses area unit at higher risk of developing foodborne health problem . Pathogens like

Listeria monocytogenes, Salmonella, and Toxoplasma gondii cause foodborne health problem . correct food storage

and preparation techniques ought to be reviewed to make sure safety . unpasteurised foods and raw or

undercooked meat, poultry, or fish ought to be avoided to cut back the danger of exposure to pathogens . Careful

sanitation strategies ought to be used, and pets shouldn’t be handled before or throughout food preparation .

Risk Factors throughout gestation

Women ought to be evaluated for factors that will place them in danger for adverse maternal and/or craniate outcomes

while they’re pregnant. If any of the subsequent risks area unit known, applicable medical and organic process

monitoring ought to be provided throughout the gestation


Risk factors at the onset of pregnancy:

Adolescence: younger than 15 years old at

time of conception or less than 3 years since

the onset of menses

Older than 35 years of age

Three or more pregnancies within 2 years

History of poor obstetric or fetal performance

Low income


Unusual dietary practices


Excessive alcohol intake

Recreational drug usea

Chronic systemic disease


Prepregnancy BMI <18.5 kg/m2 or >29.9


Multiple gestation


aRecreational drugs or over-the-counter medications or dietary supplements that have adverse effects (eg, laxatives, antacids, or herbal remedies containing teratogens


Risk factors during pregnancy :

Hemoglobin level <11 g/dL (first and third trimesters), <10.5 g/dL (second trimester);

or hematocrit <33% (first and third trimesters), <32% (second trimester)

Inadequate weight gain: <1 lb/month for very overweight women

<2 lb/month for normal or slightly overweight women

<4 to 8 lb/month for women with multiple gestation and underweight women

Excessive weight gain (>6.6 lb/month after first trimester), possibly associated with fluid retention

Ferritin level <20 g/dL

Serum folate level <3 mg/dL

Serum albumin level <2.5 g/dL

Total serum protein level <5.5 g/dL

Vitamin B12 level <80 pg/mL

Nausea and Vomiting of Pregnancy

Nausea and vomiting are the most common symptoms experienced in early pregnancy, with nausea affecting

70% to 80% of women . Dry, salty foods are traditionally recommended for resolving nausea or

vomiting; however, these foods do not always relieve symptoms . Foods with the following characteristics

are well tolerated: cold, warm, sour, creamy, crunchy, soft, wet, salty, and chocolaty . Increased olfactory

senses often are a leading cause of nausea during early pregnancy; thus, strong odors and sensitive

unpleasant odors should be avoided . Individualization in meal planning is necessary. Other

management techniques include the following recommendations :

Eat small, frequent meals and snacks.

Eat low-fat protein foods and easily digested carbohydrate foods.

Eat dry crackers before rising in the morning.

Avoid spicy foods and gas-forming fruits and vegetables.

Drink fluids between meals (milk is often not well tolerated).

Avoid drinks that contain caffeine or alcohol.

Hyperemesis gravidarum: Hyperemesis gravidarum is a condition characterized by severe, persistent

nausea and vomiting that causes dehydration, fluid and electrolyte abnormalities, acid-base disturbances,

ketonuria, and weight loss (ie, a 5% decrease from pregravid weight). Hyperemesis gravidarum occurs in

approximately 2% to 5% of pregnant women . Nausea and vomiting of pregnancy and hyperemesis

gravidarum begin in the first trimester, usually between weeks 6 and 12, and symptoms often peak between

weeks 15 and 17. Symptoms often begin to decrease by week 20 . The pathogenesis of hyperemesis

gravidarum is not well understood. Nausea and vomiting of pregnancy and hyperemesis gravidarum are

thought to be related to increased secretion of human chorionic gonadotrophin and increased estrogen levels

. Other potential causes that have been implicated but not proven include thyroid changes, such as

hyperthyroidism, and bacterial infections, such as an underlying Helicobacter pylori infection .

Complications of hyperemesis gravidarum include dehydration, hyponatremia, inadequate weight gain, and

Mallory-Weiss tears . Another complication, Wernicke’s encephalopathy, is a result of insufficient thiamin

levels that are related to vomiting or the result of glucose administration without the addition of thiamin .


Treatment of hyperemesis depends on the danger level of the patient and also the severity of

symptoms, like dehydration and also the inability to fulfill nutrition wants orally. Intensive nutrition

counseling and personal meal coming up with is that the initial line of treatment . If nutrition and behavior

modification doesn’t alleviate symptoms, medications, like metoclopramide (Reglan) and Zantac

(Zantac), or medicine medicine, like major tranquillizer (Compazine) and ondansetron (Zofran),. Patients with severe symptoms might need association with blood vessel fluids, solution replacement, or nutriment replacement with pyridoxal (pyridoxine) and vitamin B1 (thiamin) . If patients

do not reach the DRIs for B complex (1.4 mg/day) and adermin (1.9 mg/day) throughout physiological condition, dietary

supplementation ought to be provided . alittle proportion of patients with hyperemesis might

require nasogastric, surgery, or surgical procedure feedings or total channel nutrition to make sure adequate

nutrition support. solely a pair of to five of ladies with vomit gravidarumrequire total channel nutrition



Nearly all of the literature relating to nutrition support throughout physiological condition is anecdotal, consisting of case

studies. Treatment and intervention ways ar supported expertise and patient wants. If nutrition

support is indicated, treatment ought to be in line with standards made public for nonpregnant adults or in

managing coexistent medical conditions or risks (eg, refeeding syndrome).

Nutrition Support and to Specific Nutrient necessities throughout physiological condition earlier during this section.


Obesity in physiological condition not solely will increase risks for pregnant girls throughout gestation, however conjointly will increase risks

for the longer term health of the kid. fat throughout physiological condition has been related to physiological state polygenic disorder,

gestational high blood pressure, pre-eclampsia, birth defects, abdominal delivery, foetal macrosomia, perinatal deaths,

postpartum anemia, and childhood fat. additional girls ar starting physiological condition with high BMI’s, and

more ar gaining weight in {excess of|more than|far additional than|way over} the 1990 Institute of drugs (IOM) recommendations for physiological state

weight gain. Overweight and corpulent girls ar additional probably to take care of excess weight with every

successive physiological condition. those that gain additional ar additional probably to retain it and continue at a better weight

throughout their period of time, as compared to girls United Nations agency gain less weight throughout physiological condition. Weight gain

during physiological condition has conjointly been shown to possess implications for the child’s future risk of being overweight . it’s the position of The Academy of Nutrition and life science and also the yank Society for Nutrition that

all overweight and corpulent girls of generative age ought to receive guidance before physiological condition, during

pregnancy, and within the interconceptional amount on the roles of diet and physical activity in generative

health. throughout physiological condition overweight and corpulent shoppers ought to target IOM physiological state weight gain targets,

be suggested to not turn throughout physiological condition, and recommended concerning healthful ingestion habits. additionally

encouragement ought to incline to nurse and be created alert to the advantages for each the mom’s and her

child’s health.

Gestational high blood pressure

Gestational high blood pressure is outlined as pulsation force per unit area of a hundred and forty mm Hg or bigger or pulse blood

pressure of ninety mm Hg or bigger with onset once twenty weeks’ gestation. concerning twenty fifth of ladies with

gestational high blood pressure can develop pre-eclampsia, that is characterised by albuminuria (>300 mg during a 24-

hour excretion sample). pre-eclampsia happens additional usually in primigravid girls and in girls older than thirty five

years with chronic unwellness} or urinary organ disease.

Gestational high blood pressure is related to marked changes in urinary organ perform that will result in excessive

extracellular fluid retention. pre-eclampsia in the midst of generalized seizure seizures could be a condition known as toxemia of pregnancy

. pre-eclampsia sometimes happens once the twentieth week of conception. pre-eclampsia is additional common in

women with chronic unwellness} and urinary organ disease, adolescents, weedy girls with inadequate

weight gain, girls United Nations agency ar older than thirty five years, corpulent girls, girls with a history of pre-eclampsia, and

women United Nations agency ar carrying multiple fetuses .

No specific nutrition medical care has been proved to be effective in preventing or delaying pre-eclampsia and

improving physiological condition outcomes . Adequate metal, protein, energy, and metal could also be necessary.

meta-analysis of seventeen randomised controlled trials complete that {calcium|Ca|atomic number a pair of0|metallic element|metal} supplements (1 to 2 g/day) reduced

blood pressure and also the risk of pre-eclampsia however had no vital impact on reducing maternal and child

morbidity and mortality . Studies of alternative nutrients, like vitamins C and E, have yielded inconclusive

results. The effectiveness of dietary modifications, as well as Na restriction, metallic element supplements, zinc

supplements, and consumption of fatty fish oils, has not been proved . Diuretics ought to be avoided unless

strict medical management is provided





Specific Nutrient needs throughout Lactation

Breastfeeding is associated

with a reduced risk of otitis, inflammatory disease, respiratory disorder, unexpected SIDS syndrome,

necrotizing enterocolitis, obesity, and cardiovascular disease. Breastfeeding is additionally related to improved maternal

outcomes, as well as a reduced risk of breast and female internal reproductive organ cancer, kind two polygenic disease, and postnatal depression.



Energy: the typical energy prices of lactation square measure five hundred kcal/day within the 1st vi months and four hundred kcal/day within the

second vi months. Excessive restriction of energy (<1,800 kcal/day) might cause cut milk production.

Fluids: Daily intake of adequate fluid is inspired. Current proof doesn’t support that increasing or

decreasing fluid intake by twenty five to fifty % impacts breast milk production .

Alcohol: A wet lady ought to avoid alcohol consumption, unless it’s allowable by her MD.

Caffeine: wet girls ought to limit their daily consumption of caffein to 2 5-oz cups of occasional (<200mg) .

Fiber: The 2002 DRI for adequate intake of total fiber is twenty nine g/day for all age teams throughout lactation .

Fish: constant tips provided for maternity ought to be applied whereas breastfeeding. talk over with different Substances within the section on top of.

Omega-3 Fatty Acids: Consistent results from irregular management trials have shown that omega-3-fatty acid

supplementation (fish oil, cod, liver oil, or omega-3 [DHA]- wealthy oil) taken by pregnant girls or breastfeeding mothers will increase omega-3-fatty acid levels in each breast milk and infants’ plasma

phospholipids  . there’s a dose-response relationship between doses of DHA supplementation and breast milk DHA levels, however the saturation remains unclear . These positive changes in breast milk omega3-fatty acid compositions, however, don’t invariably show a positive have an effect on on children’s vision and cognitive development at long run follow-up



g though AIs are set for vitamin B, there ar few knowledge to assess whether or not a dietary provide of vitamin B is required in the least stages of the life cycle, and it should be that the vitamin B demand will be met by endogenous synthesis at

some of these stages.

h as a result of ten to thirty % of older folks could malabsorb food-bound B12, it’s recommended for those older than fifty years to fulfill their RDA in the main by intense foods fortified with B12 or a supplement containing B12.

i visible of proof linking vitamin M intake with ectoblast defects within the vertebrate, it’s counseled that each one ladies capable of changing into pregnant consume four hundred µg from supplements or fortified foods additionally to intake of food

folate from a varied diet.

j it’s assumed that ladies can continue intense four hundred µg from supplements or fortified food till their gestation is confirmed and that they enter antenatal care, that commonly happens when the tip of the periconceptional period—


Nutrition and dietary interventions in adults with inflammatory bowel disease

Nutrition and dietary interventions in adults with inflammatory gut sicknes




Inflammatory gut sickness (IBD) is AN inflammatory disorder of the epithelial duct (GI) tract resulting in symptoms of pain, nausea, fever, and diarrhoea.
These symptoms may result in loss of appetency, reduced nutrient intake, altered nutrient metabolism, and ultimately impaired biological process standing. Loss of appetency is possibly the results of inflammation and therefore the unharness of cytokines like IL-1, IL-6, and tumour mortification issue.
Dietary interventions in IBD specialise in maximising biological process standing, maintaining adequate intake, and avoiding foods which will exacerbate symptoms.
The prevalence of biological process deficiencies and deficiency disease has been well documented in IBD, particularly in regional enteritis (CD).
it’s necessary to spot patients UN agency ar unnourished so as to spot those patients UN agency could need biological process intervention.
Optimizing biological process standing is very important each forestall|to stop|to forestall} long health consequences of deficiency disease furthermore on prevent relapses in patients with IBD.
This topic review can discuss nutrition and dietary interventions in adults with inflammatory gut sickness.
Specific nutrient deficiencies in IBD, furthermore as growth failure and poor weight gain in kids with IBD ar mentioned individually.
Dietary risk factors for IBD are mentioned individually.

CAUSES OF deficiency disease


The factors that contribute to {malnutrition|deficiency sickness} and nutrient deficiencies in patients with inflammatory gut disease, as well as reduced nutrient intake, assimilation, and inflammation ar mentioned very well elsewhere.



The biological process standing of patients with inflammatory gut sickness (IBD) ought to be assessed to work out if dietary intervention is critical.
Measuring a patient’s biological process standing involves a comprehensive assessment.
This may embrace measure body composition, dietary intake, energy expenditure, body perform, and humour supermolecule markers.

Relying completely on humour supermolecule levels (eg, albumen and prealbumin) as definitive markers of nutrition is scant.
albumen could be a higher predictor of a patient’s clinical outcome within the hospital than of biological process standing.
Specific substance (vitamin and mineral) deficiencies may occur in patients with IBD relying upon their general biological process standing furthermore because the activity and placement of their sickness.
These is assessed by specific laboratory measures.
Global assessment tools ought to be used as a part of commonplace nutrition screening to spot at-risk, unnourished patients.
one among these tools could be a subjective world assessment (SGA) analysis.
This world assessment tool takes under consideration multiple nutrition-related factors as well as practical standing, dietary factors, multiple GI-related symptoms, weight loss, and a quick physical examination.
The SGA could be a useful gizmo and has been utilized in conjunction with measure body mass index, albumin, and trace parts in assessing the biological process standing of IBD patients.
However, in one study, patients with IBD UN agency were well nourished in line with this commonplace nutrition screening were found to possess a decrease in body cell mass (a live of metabolically active tissues) furthermore as reduced hold strength compared with controls.
A separate study documented that patients with Crohn’s sickness inactive typically had a standard body mass index (BMI) (weight in kg/height in meters) however reduced hold muscle strength per loss of supermolecule muscle mass.
These observations recommend that IBD patients could look well or maybe exhibit excess weight whereas having alterations in body composition and body perform and, as a result, could also be candidates for biological process supplementation furthermore.
Therefore, it’s prudent to confirm that each one patients with IBD ar assessed for adequacy of their biological process standing.

CONSEQUENCES OF deficiency disease


{malnutrition|deficiency sickness} in patients with inflammatory gut disease (IBD) will result in growth failure, weight loss, bone sickness, and/or substance deficiencies.

Growth failure
Chronic or intermittent growth failure, with associated time of life delay, is common in kids with Crohn’s sickness (CD) and regularly reduces adult height.
The analysis and management of growth failure in kids with IBD is mentioned in a very separate topic review.

Weight loss and reduced muscle mass
Weight loss and protein-calorie deficiency disease became less common among adults with IBD.
Historically, biological process deficiencies or the shortcoming to take care of ideal weight occurred in fifty to seventy p.c of adults with CD, and eighteen to sixty two p.c of these with colitis (UC).
A 2009 study of 102 adults with IBD found fourteen p.c of these with CD and five.7 p.c of these with UC to be unnourished primarily based upon body mass index (BMI) criteria.
However, muscle mass depletion was detected in additional than 1/2 the patients.
Muscle and fat mass depletion is related to sickness activity.
Adult patients with CD inactive typically don’t have any variations in body composition compared with healthy controls.
The primary mediators of reduced muscle mass ar inflammation (excessive katabolism, that accelerates supermolecule breakdown), diminished physical activity, and/or corticoid treatment.
Inadequate supermolecule intake may have an effect on muscle mass, however this mechanism isn’t typically relevant in adults unless the deficiency is severe and prolonged (starvation).
The supermolecule intake of youngsters with IBD is a lot of possible to be scant attributable to their comparatively high supermolecule wants for growth
Patients UN agency have lost between five and ten p.c of their lean body mass typically don’t have any clinical sequelae.
However, loss of lean body mass on the far side this threshold is related to multiplied morbidity.
As AN example, reduced muscle mass is related to poor wound healing and better rates of infection when surgery.

Bone sickness
Bone sickness (osteoporosis and/or osteomalacia) could be a common downside in IBD.
Its cause is perhaps complex.
Risk factors embrace corticoid use and/or sickness activity, age, time of life delay, and deficiencies of metallic element, vitamin D, and fat-soluble vitamin.
Prevention and treatment of bone loss in IBD consists of making an attempt to reverse or minimize these factors.
The analysis and management of IBD-associated bone sickness in kids differs in many respects from that in adults, as mentioned individually.

Micronutrient deficiencies
substance deficiencies in patients with inflammatory gut sickness ar mentioned very well elsewhere.





Dietary interventions to boost nutrition and eliminate food triggers play a job within the treatment regime in most patients with inflammatory gut sickness (IBD).
Clinical studies during this space ar little in range, typically not irregular or placebo-controlled, and contain little numbers of patients.
Still, there ar some conclusions we will draw from this body of literature.

Nutrition supplementation


Nutrition supplementation is that the administration of commercially out there supplements to extend calorie and supermolecule intake.
Oral intake is that the most popular technique of delivery, though tube feedings (nasogastric or nasoduodenal) ar used once willing oral intake is insufficient.
Liquid biological process supplementation could take the shape of AN elemental, semi-elemental, or compound diet.
every consists of liquid nutrients in AN simply assimilated kind, differing in their supermolecule source; elemental (free amino acids), semi-elemental (oligopeptides), and compound (whole protein).
The diet designated is typically supported individual preferences, individual tolerance, convenience, and cost.
Enteral nutrition (liquid food delivered orally or via tube feeding) additionally to traditional food is indicated in unnourished patients with IBD to boost biological process standing.
additionally, enteral feeding has some effectualness in inducement remission in patients with active regional enteritis (CD), though glucocorticoids seem to possess superior effectualness.
before the approval of anti-TNF compound for induction of remission in fistulizing CD, the ecu Society for Clinical Nutrition and Metabolism tips suggested enteral nutrition be used as medical aid in active CD, primarily once treatment with glucocorticoids isn’t possible.
a scientific review showed that there was no distinction within the induction of remission in CD once completely different formula compositions (elemental, semi-elemental, and polymeric) were compared.
A non-significant trend affirmative terribly low fat and/or long chain lipide content was conjointly found, however remains to be confirmed.
more analysis of six trials found that corticoid medical aid was more practical for inducement remission of active CD than was enteral nutrition.
Supplemental enteral medical aid may be effective in maintaining remission in CD, however this has not been definitively established.
It is postulated that AN oral supplement reduces exposure to the substance properties of traditional food whereas boosting caloric intake.
A systematic review tried to appear at enteral nutrition for the upkeep of remission in Crohn’s sickness.
2 irregular trials were known that met inclusion criteria, however a pooled applied mathematics analysis wasn’t doable thanks to variations within the management interventions and outcome assessments.
The following studies describe the potential advantages of this treatment approach:
• In one study, patients UN agency received a 0.5 elemental diet and a 0.5 traditional diet had a lower relapse rate compared with patients UN agency received a standard unrestricted diet.
• In another study, patients with Crohn’s sickness UN agency were taking in traditional food were appointed to receive either elemental or compound biological process supplements.
• Both approaches were equally effective for maintenance of remission and allowing steroid withdrawal.
• The advantage of oral supplements was conjointly represented in a very third study during which traditional table food was supplemented with a liquid formula.
• Twenty-eight unnourished patients UN agency received AN oral supplement had improved well being, improved steroid withdrawal, diminished CD activity, and improved biological process standing.
• Finally, ANother study irregular thirty-nine patients with CD to either traditional food or traditional food supplemented with an elemental diet.
• At one year, remission rates were higher in those that received the supplemental elemental feeding (48 versus twenty two percent).
Limited information exist on enteral biological process medical aid in patients with UC.
One prospective irregular trial compared enteral nutrition with total duct nutrition as AN adjunct medical aid in severe UC patients on corticoid medical aid.
Remission rates were similar within the 2 teams.
Routine vitamin pill supplementation with metallic element is usually recommended in IBD seeable of the nutrient deficiencies determined.
Patients may need supplementation with specific micronutrients.
it’s conjointly affordable to recommend supplementation with B vitamin primarily based upon information suggesting that it’d defend against the event of abnormalcy.
Perioperative nutrition supplementation has not been incontestible to boost outcome in surgical patients.
However, some severely unnourished patients would possibly take pleasure in perioperative artificial feeding.

Total duct nutrition


Total duct nutrition (TPN) consists of administering a biological process formula intravenously once no food is given by the other route.
The yank Gastroenterological Association technical review of six trials complete that feeding provided no profit within the routine treatment of IBD and should be appreciate enteral nutrition once treating patients with active CD of the tiny gut.
However, feeding features a role in severe cases of active CD wherever enteral nutrition supplementation isn’t tolerated or commonplace drug treatment isn’t effective.
feeding is additionally administered to correct biological process deficiencies before surgery or as AN in-home possibility for CD patients whose different is prolonged hospitalization or early surgery.
Home feeding may be used for CD patients with multiple little gut resections leading to short gut syndrome.

Elimination diet


AN elimination diet involves removing a food from the diet for a amount of your time and seeing whether or not symptoms resolve throughout that point.
In patients receiving enteral nutrition, it involves introducing one new food at a time to spot foods that precipitate IBD symptoms.
several patients will establish foods that they believe could precipitate or worsen their sickness and it’s affordable for them to avoid such foods.
victimisation AN elimination diet to spot at-risk foods could decrease the likelihood of a “flare” of IBD.
Three studies offer support for this treatment approach.
• One trial compared the utilization of glucocorticoids versus AN elimination diet in seventy eight patients UN agency had achieved a remission of their IBD flare by the utilization of AN elemental diet feeding.
• Patients were tutored to introduce one new food cluster daily and to avoid foods that they knew antecedently resulted in causative their IBD symptoms.
• Relapse rates at 2 years were lower within the diet-treated than within the steroid-treated cluster (62 versus seventy nine percent).
• Food intolerances to cereals, lactose, and yeast product were common.
• Another study evaluated the utilization of AN elimination diet versus AN unrefined saccharide, fiber-rich diet in patients with CD UN agency were presently inactive.
• Relapse rates at six months were one hundred pc within the unrefined saccharide, fiber-rich diet versus thirty p.c on the elimination diet.
• In a longer-term study, thirty one patients with CD UN agency obtained clinical remission when four weeks of enteral feeding were followed for thirty six months.
• Twenty of the patients were placed on an outlined dietary elimination protocol, whereas the remaining patients were continued on AN unrestricted diet.
• Of the fourteen patients UN agency completed the elimination diet method, 3 relapsed.
• Of the eleven patients consumption an everyday diet, 9 relapsed.
• Almost all of the relapses occurred within the initial six months.
Lactose elimination is notably useful.
inherited disease is usually noted in patients with colitis.
Patients with suggestive symptoms ought to bear a disaccharide breath chemical element take a look at to verify the identification.
Calcium supplementation ought to be maintained in patients with restricted disaccharide intake to attenuate the danger of bone loss.

Low saccharide diet


There are anecdotal reports of a coffee saccharide diet being useful in preventing relapse in patients with inflammatory gut sickness.
there’s no recommendation from any major aid society supporting this intervention and there’s very little literature during this arena. One study irregular 204 patients with CD inactive to polyunsaturated fatty acid fatty acids, a placebo, or a coffee saccharide diet.
In AN intent-to-treat analysis, neither the polyunsaturated fatty acid carboxylic acid supplementation nor the low saccharide diet resulted in any improvement in relapse as compared to placebo.
The Specific saccharide Diet (SCD) could be a terribly restrictive low saccharide diet that has been promoted for multiple chronic and response diseases, as well as IBD, autism, and upset.
The diet is made upon the premise that enteral microbes that contribute to the event of IBD use carbohydrates as their primary energy supply, resulting in the assembly of acids and toxins which will injure the tiny internal organ, more impairing saccharide digestion and absorption.
The DS is grain-free, lactose-free, and sucrose-free.
It conjointly limits the intake of some legumes and tubers and it doesn’t leave the intake of processed foods thanks to additives.
The diet will leave the intake of unprocessed meats, poultry, fish, eggs, honey, non-canned vegetables, some legumes, fruits, nuts, do-it-yourself yoghurt, and a few lower-lactose cheeses (eg, cheddar).
The data on the DS ar restricted to a case report of 2 patients UN agency improved on the diet and lots of patients notice the diet tough to follow thanks to its restrictive nature.
additionally, some clinicians specific concern that it may lead to biological process deficiencies.
irregular trials examining the DS ar needed before it is suggested.



Probiotics reside, nonpathogenic micro-organisms (eg, yeast, lactobacilli) that, once eaten, ar believed to possess the potential to exert a positive influence on host health and physiology.
In UC patients following surgery, there seems to be a profit to the utilization of the probiotic VSL-3 (CSL metropolis, Italy) (3 to six g/day) for the bar of repeated pouchitis.
additionally, one study found that the utilization of the probiotic Escherichia coli Nissle 1917 (Mutaflor®, Ardeypharm Herdecke, Germany) was as effective for the treatment of relapse in UC patients because the drug mesalamine .
There haven’t been convincing information on the effectualness of varied probiotics for the bar of relapse in CD.

Other dietary interventions

Other dietary interventions are considered; but, conflicting information exist relating to their use.


The advantage of increasing dietary fiber in IBD patients remains arguable.
Fiber features a useful result on commensal gut bacterium.
Some dietary fiber upon metabolism can kind short-chain fatty acids, that are shown to stimulate water and atomic number 11 absorption within the colon and to market tissue layer healing.
Dietary fiber could have a job within the maintenance of remission.
In one study, for instance, the consumption of Plantago ovata seeds (10 grams doubly daily) was as effective as a maintenance dose of mesalamine (500 mg 3 times daily) in maintaining remission for up to twelve months in patients whose colitis was in scrutiny and clinical remission at the beginning of medical aid.
A retrospective study of thirty two patients with CD reported a reduced rate of hospital admissions and surgeries in a very fiber-supplemented cluster compared with thirty two patients in a very management food cluster.
However, alternative studies have didn’t demonstrate improved clinical outcomes of CD patients consumption a fiber-rich diet.

Omega-3 unsaturated fatty acids



the prevailing information don’t support the utilization of fish oils for maintenance of remission in UC or CD.
Omega-3 unsaturated fatty acids (03PUFA) ar potent immunomodulatory substances.
They are typically obtained from fish oils and contain omega-3 fatty acid and omega-3.
the power of O3PUFA to downregulate the inflammatory response has been shown in each animal models and in humans.
A irregular controlled trial incontestible that animal oil supplementation reduces the assembly of inflammatory cytokines and animal oil supplementation has been shown to cut back inflammation and therefore the dose of antiinflammatory medication needed to market weight gain in patients with IBD.
However, 2 massive placebo-controlled trials in CD and systematic reviews of clinical trials in patients with UC and CD found that oral eaten animal oil supplementation, while safe, is ineffective for inducement or maintaining remission in either UC or CD.


The data relating to the utilization of antioxidants in IBD aren’t substantial enough to form a recommendation.
Antioxidants ar substances that neutralize element free radicals, metabolic product that ar multiplied throughout inflammatory states and lead to vital tissue injury.
One irregular controlled trial of fifty seven patients employing a combination of ANtioxidants as an antiinflammatory supplement for four weeks found that treatment made a discount in measured indices of aerophilous stress with no result on sickness activity.

SUMMARY and proposals


• The prevalence of biological process deficiencies and {malnutrition|deficiency sickness} has been documented in inflammatory gut disease (IBD), particularly in regional enteritis.
• it’s necessary to spot patients UN agency ar unnourished so as to spot those patients UN agency could need biological process intervention.
• Measuring a patient’s biological process standing in IBD involves a comprehensive assessment. we recommend employing a subjective world assessment tool in conjunction with measure body mass index, albumin, and trace parts to assist in distinguishing at-risk, unnourished patients.
• Nutritional supplementation is crucial for patients with proof of deficiency disease to extend calorie and supermolecule intake.
• biological process supplementation may have effectualness within the induction and maintenance of remission in adults with regional enteritis, however doesn’t replace alternative treatments.
• Multivitamin supplementation is usually recommended for all patients with IBD.
• We recommend use of AN elimination diet if a patient experiences a relapse following remission or if they establish foods that they believe could precipitate or worsen their sickness.
• Lactose elimination is notably useful.
• Patients with suggestive symptoms ought to bear a disaccharide breath chemical element take a look at to verify the identification.
• metallic element supplementation ought to be maintained in patients with restricted disaccharide intake to attenuate the danger of bone loss.
• For colitis patients with repeated pouchitis, the probiotic VSL-3 (3 to six g/day) has been shown to be of profit in preventing relapse.
• Conflicting information exist relating to the advantages of alternative dietary interventions like low saccharide diets, fiber, polyunsaturated fatty acid unsaturated fatty acids, and antioxidants.
• Total duct nutrition features a role in severe cases of active {crohn’s disease|regional enteritis|regional ileitis|Crohn’s disease|colitis|inflammatory gut disease} wherever enteral nutrition supplementation isn’t tolerated or commonplace drug treatment isn’t effective or for a few patients with short bowel syndrome.


moderate to severe burn patients

moderate to severe burn patients


moderate to severe burn patients

Nutritional support represents one among the foremost important cornerstones within the management of patients with a moderate to severe burn injury.

Nutritional support represents one among the foremost important cornerstones within the management of patients with a moderate to severe burn injury.
Clinical monitoring is that the key tool for assessment of the adequacy of nutritional support. Laboratory markers for immune reaction, indirect calorimetry, and weight and composition also are used.
This topic reviews assessment of the adequacy of nutritional support in burn patients.
Patient selection, timing, delivery, and kinds of nutrition support, calculating caloric requirements for burn patients and selection of enteral formula are discussed elsewhere.
The adequacy of nutritional support is monitored by assessing the patient’s clinical course and wound healing.
Trends, instead of single measurements or point estimates, should be monitored.
Clinical course
Parameters wont to evaluate the clinical course include:
• Hemodynamic stability
• Respiratory status
• Functional status
• Evidence of infection or sepsis
• Tolerating diet
Wound healing
An experienced clinician should evaluate the patient’s burns daily.
Assessment of the wound includes recording size, depth, condition of the bottom, and pain.
This examination allows for early identification of delayed or inadequate wound healing, both of which are markers of nutritional deficiencies .

moderate to severe burn patients

Burning is a type of injury to the muscle tissue or skin due to heat, electricity, chemicals, friction, or radiation.

TOTAL weight


Total weight (TBW) measures two components: lean weight (muscles, bones, tendons, ligaments, and water) and fat weight. While measurements of TBW are helpful in evaluating nutritional status in healthy individuals, the numerous volume of fluid required for resuscitation in burn patients limits its value to assess nutritional status, particularly during the acute phase of burn care.
The daily measurement of TBW is employed within the majority of burn centers within the u. s. mutually indicator for monitoring and evaluating nutritional status.
Long-term trends in TBW are a helpful indicator of nutritional status when patients enter the rehabilitative phase of burn care.



Maintenance of lean body mass (LBM) represents one in every of the central tenets of nutritional support in burn patients.
LBM theoretically will be monitored using body composition technology like total body potassium counting (K-counter), dual X-ray absorptiometry (DEXA) scanning, and bioimpedance analysis (BIA).
We don’t use any of those technologies, as further studies are needed to work out the utility and appropriateness of routine use within the burn care setting.
No studies of BIA are published in burn patients, though the bedside nature of BIA makes it convenient as a routine clinical tool.
Both K-counter and DEXA are routinely employed in long-term studies of pediatric burn patients, but haven’t been used as a routine component for evaluating clinical nutrition status.
Body composition assessment by current techniques can’t be reliably used as a method to watch nutritional status in burn patients due to the edema and fluid shifts related to the inflammatory response to the burn injury.




Indirect calorimetry (IDC) may be accustomed determine the nutritional requirements, likewise as function an indicator of response to nutritional support, particularly within the difficult to manage patient.
The utility of IDC is controversial, particularly as one measurement point.
One of the best limitations of IDC is that energy expenditure fluctuates with activity.
We recommend using trends in IDC as a more reliable estimate of adequate nutritional support than one measurement.
IDC is monitored twice per week in our center, with adjustments in nutritional support occurring no over twice per week based upon trends in IDC, balance data, and clinical progress.
Two-thirds of responding centre dieticians indicated that they used IDC to assess energy demands in adult patients.


moderate to severe burn patients

Burning is a type of injury to the muscle tissue or skin due to heat, electricity, chemicals, friction, or radiation.

The assessment of adequate nutritional support must address both energy requirements and protein demands of burn patients.
balance, therefore, plays a very important role in assessing nutritional adequacy following burn injury.
Measuring urinary urea nitrogen (UUN) and calculating balance on a weekly basis allows approximation of the trend in nitrogen breakdown and appropriate adjustment of protein goals, particularly when employed in conjunction with the previously described methods of nutrition status monitoring.
In children with severe burns, UUN is imprecise, reflecting the diminished reliability of UUN measurements in patients with hypercatabolic responses



The physiologic changes that accompany a burn injury make it difficult to accurately interpret laboratory markers.
The practice at our center is to not use visceral proteins (eg, albumin) to watch nutritional status, as our experience with them has been unreliable. Furthermore, while there are markers that correlate with compromised nutritional status, they are doing not provide a meaningful measure of overall trends in nutritional status for burn patients.

Serum albumin


Serum albumin doesn’t correlate with balance in burn patients.
Serum albumin levels decrease dramatically with injury and remain chronically depressed following burns, even when other indicators suggest adequate nutritional support.

Inflammatory response proteins

moderate to severe burn patients

Nutritional support represents one among the foremost important cornerstones within the management of patients with a moderate to severe burn injury.

We don’t monitor the adequacy of nutritional support with transthyretin, transferrin, retinol-binding protein, and C-reactive protein during the convalescent phase.
If these protein markers are monitored, we recommend that they be used only in conjunction with the assessment of the clinical course and wound healing.

Transthyretin (prealbumin), C-reactive protein, retinol-binding protein, and transferrin have all been considered as laboratory markers for assessing the efficacy of nutritional support in burn patients.
Transthyretin, like albumin, decreases dramatically following burn injury, although it gradually recovers with adequate nutrition and because the inflammatory response subsides.
there’s a positive association with transthyretin level and wound healing and a particularly weak association with balance.
In a cross-sectional study of fifty burn patients, transthyretin was the factor significantly related to graft healing.
Transthyretin levels that don’t improve with adequate nutrition and a normalizing C-reactive protein is also indicative of either a protein or calorie deficiency.
Retinol-binding protein and transferrin didn’t demonstrate a meaningful correlation with balance.


SUMMARY and suggestions


Nutritional support represents one in all the foremost important cornerstones within the management of patients with a moderate to severe burn injury.
• The adequacy of nutritional support is best assessed by the clinical course and wound healing.
• When utilized in conjunction with daily clinical assessment, evaluating trends in total weight, indirect calorimetry, and laboratory results is helpful in assessing adequacy of nutritional support.
• Single random measurements aren’t useful.
• Most burn centers measure total weight (TBW) daily.
• The long-term trend in TBW may be a helpful indicator of nutritional status when patients enter the rehabilitative phase of burn care.
• Maintenance of lean body mass (LBM) is one in all the central tenets of nutritional support in burn patients, but there’s no proven method for accurate assessment of LBM.
• We make adjustments in nutritional support no over twice per week based upon trends in indirect calorimetry, urinary urea nitrogen, and clinical progress.
• Laboratory tests are difficult to accurately interpret following a burn injury. If laboratory tests are wont to assess nutritional status, they must be utilized in conjunction with the assessment of the clinical course and wound healing

alternative remedies in rheumatic disorders

alternative remedies in rheumatic disorders

alternative remedies in rheumatic disorders

Many patients with rheumatic disease suffer physically and emotionally.
they need to learn to address the illness,

“All who drink of this remedy are cured, except those that die. Thus, it’s effective for almost the incurable.” Galen.
What is the role, if any, for “complementary” and “alternative” remedies within the routine therapy of patients with rheumatic diseases? Despite considerable interest in these therapies , I don’t consider that anything truly clinically important has emerged in rheumatology .

“Alternative” or “complementary” therapies in medicine have gained public attention and implied endorsement by the u. s. government:
• A survey of patients followed privately and university-based rheumatology practices found that roughly two-thirds had used some type of complementary or alternative therapy .
• A subsequent survey of 232 consecutive patients in both private and university rheumatology practices found that one-third were actively using one or more of those therapies during the course of 1 year .
• In 1992, Congress established an Office of different Medicine, now renamed the National Center for Complementary and medicine, at the National Institutes of Health (NIH), with an annual budget now in way over $100 million.
It therefore behooves clinicians to be aware of a number of these “complementary” and “alternative” remedies available for rheumatological patients so as to be able to effectively communicate with patients and colleagues.



The American College of Rheumatology (ACR) established a committee in 1993 to handle pertinent issues originally surrounding the efficacy of those remedies.
At that point, the committee deliberately selected the term “questionable,” following the approaches of other groups.
This permitted the avoidance of other terms that euphemized questionable remedies.
to evolve to current trends, the ACR later adopted the terms “complementary” and “alternative.”
There are three forms of therapies:
• Genuine, defined as those proven acceptably safe and effective
• Questionable
• Ineffective
I have come to prefer the terms “mainstream” and “nonmainstream” to best categorize how therapies are conceived.
These names are preferable to other terms for possible remedies, like “unapproved” (eg, by the Federal Drug Administration), “false” (disproven), “unproven” (experimental), “dubious” (very doubtful), “non-standard” (falling wanting practice standards), “irregular” (not employed by mainstream medicine), or perhaps “alternative” or “complementary” (reflecting various questionable or conventional treatment options) .


Many patients with rheumatic disease suffer physically and emotionally.
they need to learn to address the illness, the constraints imposed by the restrictions of medication, and therefore the considerable uncertainty concerning outcome. These adjustments don’t seem to be always easy.
Patients want hope for a cure or for relief.
Nonmainstream approaches offer hope.
Patients may therefore turn from science and seek understanding and relief (and empowerment) from questionable sources .
we will understand this quest and sympathize since we’ve got undoubtedly also sought and used questionable remedies (such as soup for a chilly or a rub for an ache).
Increasingly, many seek “complementary” and “alternative” remedies as a way of life choice .
Recent observations suggest that a lot of patients seeking “complementary” and “alternative” therapies do so in response to psychosocial distress, not necessarily thanks to severe or unresponsive illness .



The medical response to “complementary” and “alternative” remedies therefore remains problematic.
Our different options include:
• We can inform ourselves, which is that the intent of this section.
• We can dismiss them.
• We can establish repositories of data about them, which the American College of Rheumatology and Arthritis Foundation has done .
• We can try and communicate with patients and also the public through the media. However, “Doctor’s diet cures arthritis” makes instant headlines within the lay press; by comparison, “Doctor’s diet doesn’t cure arthritis” takes years of research, writing, and revision before appearing within the rheumatology literature, and has limited impact upon physician and patient practices .
• We can aggressively combat public perceptions within the press and within the courts, as does the National Council Against Health Fraud.
• Although this is often a worthy effort, its success is additionally limited .
Education and communication must suffice until our science improves .

Many physicians have a too frequent impulse to disdain and sometimes to ridicule “complementary” and “alternative” remedies.
we’ve got a conventional intellectual view of science and also the concept that human problems will be understood and solved by the suitable application of science. However, science isn’t proof against superstition, fraud, errors, conservatism, pigheadedness, fashion, and trends (eg, tonsillectomies, adenoidectomies, irradiation for acne or autoimmune disease, and iced saline lavage for GI bleeds).
There are several possible explanations for our dismissal of “complementary” and “alternative” remedies from legitimate study.
Arguably, we not dismiss CAM.
First, non-mainstream approaches evoke discomfort and prejudice, and appear to defy rational explanation.
Second, quackery is purveyed by practitioners whom we sometimes consider unsavory and our intellectual inferiors since we don’t share their belief system, are offended by their audacity, or may feel demeaned if we condescend to contemplate their notions.
It may once have seemed absurd to propose that diet, antibiotics, or red peppers might sometimes help arthritis or that antibiotics would help ulceration disease. However, the outright rejection of “complementary” and “alternative” remedies risks missing potentially beneficial therapies .



Although some may argue that patients should be permitted to do “complementary” and “alternative” therapies because they’re often a minimum of innocuous, I argue that it’s not responsible to use therapies generally not considered acceptably safe and effective.
As examples, some “complementary” and “alternative” therapies aren’t innocuous and are occasionally harmful:
• There are documented instances of patients who received therapies apart from those promised and suffered from adverse results, including marrow aplasia, serious infections from contaminants, and death.
• Patients seeking “complementary” and “alternative” remedies may inappropriately neglect their illness .
• Expenditures on “complementary” and “alternative” remedies may divert scarce health-care resources from more appropriate areas.
I will next consider selective and representative samples of “complementary” and “alternative” remedies.
a close discussion of those remedies is beyond the scope of this presentation, but has been reviewed elsewhere .

alternative remedies in rheumatic disorders

the science or practice of the diagnosis, treatment, and prevention of disease (in technical use often taken to exclude surgery).





Prominent “complementary” and “alternative” remedies for rheumatic disorders include
• Diet
• Vitamins and minerals
• Nutritional supplements
• Fish oils
• Antimicrobials (nitroimidazole, rifamycin, ceftriaxone , tetracyclines, ampicillin , and amantadine )
• Biologic therapy (thymopoietin, transfer factor, placenta-derived factors, venoms, and herbal remedies)
• Other pharmacologic agents (cis-retinoic acid, isoprinoside, amiprolose, thalidomide , and dapsone )
• Topical agents ( dimethyl sulfoxide [DMSO])
• Mechanical/instrumental therapies (hyperbaric oxygen, laser irradiation, acupuncture, photopheresis, electromagnetic radiation), chiropractic manipulation, homeopathy, biofeedback, exercise, yoga, et al. (eg, sitting in abandoned uranium mines)
A microbial etiology for autoimmune disease (RA) has long been a horny but unproven hypothesis.
However, antimicrobials may well be useful if this hypothesis were true.
The following are instructive clinical experiences concerning therapy using antimicrobial agents for patients with rheumatic disorders .
However, the subsequent reflect largely isolated and unconfirmed observations.
• Nitroimidazole antimicrobial drugs are tried for the treatment of RA due to the efficacy of levamisole, another imidazole derivative, and since of claims that RA was caused by Amoeba limax. Results, however, haven’t been impressive .
• Rifamycin, an antibiotic that blocks DNA-dependent RNA polymerase and inhibits cellular protein synthesis, was promising for the treatment of rheumatoid knee synovitis in preliminary observations .
• Tetracycline therapy has also been tried based upon a putative mycoplasma etiology for RA.
• Such therapy was considered ineffective for several years. This issue has been revisited, however, since later scientific work found that tetracyclines, particularly minocycline , may have significant physiologic effects, including reduced collagenase activity, lessening of bone resorption, and perturbation of T-cell and neutrophil function. additionally, these drugs were found to be antiproliferative, antiinflammatory, and antiarthritic in animal and possibly human arthritis. Thus, tetracycline therapy is not any longer considered “complementary” or “alternative”.
• Patients with chronic inflammatory arthritis and antibody titers to Lime disease spirochete of 1:64 or greater have had encouraging responses to ceftriaxone .
• Ampicillin was reported to be beneficial under certain conditions for patients with RA .
• Amantadine , an medicine, was useful for a gaggle of patients with teenage-onset juvenile idiopathic arthritis who had elevated antibody titers to influenza A and were born during an influenza epidemic .
If observations suggesting a take pleasure in antimicrobial and/or antiviral therapy are consistently confirmed, either chronic arthritis in some patients results from bacterial, spirochete, or infection, or such therapy could also be antirheumatic.

Foods, diet and nutritional supplements
For years, special diets for patients with arthritis were relegated to quackery. it had been shortly ago that the Arthritis Foundation presented “The Truth about Diet and Arthritis,” stating “if there was a relationship between diet and arthritis it’d are discovered way back.
the easy fact is that there’s no scientific evidence that any food has anything to try to to with causing arthritis and no evidence that any food is effective in treating or ‘curing’ it .

We et al have now reexamined this notion.

balanced nutrition

the process of providing or obtaining the food necessary for health and growth

• How might food affect arthritis? First, some patients with rheumatic disease could also be allergic to certain foods and have symptoms that may be a manifestation of allergy.
• Second, certain sorts of diets with particular amounts of calories, protein, and fatty acids may affect the immunologically-mediated inflammation that happens with arthritis .
• Is there a diet for arthritis? there’s no compelling evidence at this time that any diet aside from a healthy, balanced one is consistently helpful to patients with arthritis.
• One study of a well-liked diet (the elimination of beef, additives, preservatives, fruit, dairy products, herbs, spices, and alcohol) for patients with arthritis found no consistent salutary effect on disease activity .
• Is arthritis caused by food hypersensitivity in some patients? Physicians and patients remain intrigued that arthritis may occasionally be the results of hypersensitivity to foods.
• As examples: palindromic rheumatism has been related to sodium nitrate; Behçet’s syndrome with black walnuts; systemic LE (SLE) with canavanine in alfalfa (which may cross-react with native DNA or activate B lymphocytes) and with hydrazine, and RA allegedly with many substances including house dust, tobacco, smoke, petrochemicals, tartrazine, dairy products, wheat, corn, and beef.
• In addition, rheumatoid-like synovitis in rabbits has been induced by dietary milk .

Careful, prospective, placebo-controlled, double-blind studies confirmed (for selected patients) that inflammatory arthritis can be related to foods.
• One patient, for instance, had half-hour of morning stiffness, nine tender joints, and three swollen joints on her regular diet .
• Virtually all of those findings disappeared after a 3 day fast.
• they may then be reproduced by milk challenge but not with other foods.
• The role of fish or plant oils or diets? Nutritional status exerts a profound influence on immune responsiveness and disease expression.
• As an example, mice with SLE or rats with arthritis that are fed diets rich in omega-3 (a present, substituted, polyunsaturated carboxylic acid analog) fared better than did control animals.

Clinical trials of fish oils and plant seed oils have suggested a modest decrease in certain symptoms with therapy in patients with RA but not SLE .
• Beneficial effects of animal oil supplementation could also be enhanced by limiting the dietary intake of polyunsaturated oils (eg, corn, soybean, safflower, sunflower) to 10 grams or less per day .
• Although capsules of animal oil are convenient, the quantity of omega-3 contained in each capsule is corresponding to that found in one mL of cod liver oil; thus, a 20 mL dose of cod liver oil, which is that the usual daily dose, provides roughly the identical amount of such fatty acids as that found in 20 capsules of animal oil.

In comparison to a typical “Western” diet, a Mediterranean diet generally derives fewer calories from animal material and more from cereals and vegetable oils, particularly vegetable oil.
• Liberal intake of fresh fruits and beans yet as a moderate daily consumption of wine is additionally typical of this kind of diet. The possible effects of a Mediterranean diet (MD) was the topic of a study within which 51 patients with RA were randomly assigned to a MD or to an omnivorous cuisine for 12 weeks .
• While those subjects who ate a MD had more improvement in some measures of disease activity, other indicators were unchanged.
• There was little change noted in patient global-assessments within the omnivorous subjects nor in their disease activity scores.
• Since the intervention and assessment weren’t “blinded” in any fashion, a big issue within the group assigned to the Mediterranean diet can not be excluded.

These observations suggest that dietary factors that modify arachidonic acid-derived prostaglandin or leukotriene generation affect inflammatory and immunologic responses and should therefore ameliorate symptoms of rheumatic diseases.
• The role of nutritional supplements? variety of drugs, including copper, zinc, and vitamin B, are reported to be helpful for patients with arthritis. In general, however, the evidence in support of such claims is scant
• As an example, although copper salts are antirheumatic in clinical trials, their use was related to many adverse effects; as a result, copper salts haven’t evolved as a very important therapeutic agent.
• In another study, some patients with RA benefited from oral zinc; however, the development was modest and inconsistent, and wasn’t confirmed in other studies.
• In addition, although the administration of L-histidine has helped atiny low set of patients with RA, it’s not emerged as a crucial agent. Evidence to support the efficacy of ascorbic acid for arthritis patients is additionally lacking.

While concentrations of pyridoxal are reduced within the serum of patients with RA and levels of pyridoxal 5′ phosphate, the active metabolite of B6, are inversely correlated with disease activity ; there’s at the present no convincing evidence that supplementing the diet with vitamin B has any beneficial effect on disease activity or associated disorders.
A general overview of dietary supplements is provided elsewhere.
Herbal remedies
Various herbal preparations are undergoing investigation for possible benefit for arthritis.
A good example may be a Chinese herbal remedy (an alcohol extract of Tripterygium wilfordii Hook F, TwHF) for autoimmune disease (RA), with suggestive immunosuppressive properties .
A handy study randomly assigned 35 patients with RA to placebo or one in all two doses (180 or 360 mg/day) of an alcohol/ethyl acetate extract of the herb.
A dose-response relation was noted with ACR 20 responses of 80, 40, and 0 percent within the high-dose, low-dose, and placebo groups, respectively; ACR 50 responses were note in 50, 10, and 0 percent.
Self-limited diarrhea developed more often during active treatment than with placebo (in approximately one-third and none, respectively).
Another randomized trial compared TwHF with sulfasalazine in 121 patients with RA; only 62 and 41 percent of these receiving TwHF (60 mg three times/day) and sulfasalazine (1 gm twice/day), respectively, completed the study .
Among those that completed the study, an ACR20 response was achieved significantly more often after 24 weeks of treatment by patients receiving TwHF (68 versus 36 percent).
HAQ scores and IL-6 levels improved more with TwHF, but there was no difference in ESR and CRP.
There was a 2.4 point improvement within the DAS28 with TwHF. Adverse event rates were similar within the two groups.
Additional clinical study and further investigation into the mechanism of the beneficial antiinflammatory effects of this herbal preparation are valuable.
Additional herbs and dietary supplements that are studied in patients with RA include the following;
• Those that showed some promising results: two Ayurvedic mixtures, borage, garlic, Phytodolor, Uncaria tomentosa, fish oil, and selenium
• Others that weren’t related to any clinical improvement, including blackcurrant (Ribes nigrum), Boswellia serrat, herb (eg, from common evening primrose and Oenothera lamarckiana), feverfew (Tanacetum parthenium), and green-lipped mussels.
However, all the studies were small, the results were modest at the best, and wish confirmation in standardized trials.
Other herbal preparations are promoted as treatments for osteoarthritis. One systematic review concluded that there was so far no evidence of a major benefit with Eazmov, Gitadyl, or ginger extract; by comparison, there was some evidence of efficacy (decreased pain) for Reumalex (a combination of willow bark, guaiacum resin, rattle-top, sarsaparilla, and poplar bark), willow bark alone, nettle, Articulin F (a proprietary combination of salai [Indian frankincense], Withania somnifera [winter cherry], turmuric and zinc), devils claw, extract of soybean and avocado unsaponifiables (ASU), Phytodolor (a combination of poplar bark, ash bark, and goldenrod), and capsaicin cream.
These would require rigorous well controlled randomized study to verify putative salutary effects.
A general overview of herbal medicine is provided elsewhere.
Some of the newer biologic agents, like monoclonal antibodies, interleukins, cytokines, and similar products, are exciting due to their potential, and for a few, their established clinical value.
Even those biologic agents whose therapeutic roles are still being evaluated, don’t seem to be usually considered “alternative” remedies .
Additional “complementary” and “alternative” remedies and their possible efficacy include the following:
• Although venoms affect inflammatory and immune responses in vitro, they need no documented clinical utility.
• Indeed, a “beekeepers” arthritis has been reported .
• New pharmacologic approaches are of interest; some (such as dapsone ) may receive further attention.
• Dimethyl sulfoxide (DMSO) and hyperbaric oxygen aren’t of proven value.
• Laser therapy, utilizing low power light sources, has been evaluated for both arthritis and osteoarthritis.
• a scientific review of reported clinical trials reported that laser treatment of the hands of patients with autoimmune disorder provided significant benefits .
• By comparison, consistent trends haven’t been observed in those with osteoarthritis.
• It is difficult to supply any specific recommendations regarding low level laser therapy due to variations in protocols, including laser intensity, duration, wavelength, and frequency of treatments.
• Homeopathy and biofeedback have shown varying degrees of benefit in certain situations; however, these studies haven’t been confirmed.
• The subject of homeopathy is reviewed well elsewhere.
• Acupuncture has not been found effective in patients with RA, and isn’t a risk-free procedure.
• A review of reported complications included two deaths thanks to needle injuries to the center and 90 pneumothoraces, of which two were fatal.
• Although popular, permanent magnets appear to be without benefit in patients with chronic low back pain as demonstrated during a pilot randomized trial of 20 patients .
• They also appear to be no better than placebo in relieving wrist pain in patients with carpal tunnel syndrome .
• Improvement in pain and performance are reported in some studies of patients with osteoarthritis of the knee or hip .
• Blinding could be a problem, as subjects can often discern the difference between magnetic devices and nonmagnetic or weakly magnetic (placebo) controls.
• Pulsed magnetic fields weren’t simpler than a sham treatment for patients with osteoarthritis of the knee .
• Reports have evaluated the possible efficacy sure enough patients with rheumatoid or osteoarthritis of multiple different therapies, including thalidomide , manipulation , electromagnetic wave , photo- (chemo-) pheresis , yoga , mud , prayer or distant healing , Ayurvedic medicine , and maybe soup .

As an example, glucosamine hydrochloride and chondroitin sulfate have undergone vigorous long-term evaluation in an exceedingly study sponsored by the NIH. Although generally safe, these remedies should be considered questionable (or investigational) approaches.
• I am also not awake to appropriate evidence-based observations to support recommendations for the employment of methonyl-sulfonyl-methane (MSM) , cetyl myristoleate , ginger , or zinaxin .
• Suggestive observations are available for s-adenosylmethionine (SAM-E) ; however, its use should be considered with caution in patients with RA on methotrexate .
• Pain relief from the appliance of leeches was reported in an exceedingly study of 51 patients with osteoarthritis who were randomly assigned to own leeches (Hirudo medicinalis) or topical diclofenac applied to an affected knee .
• Significantly more pain relief was reported with leeching than with diclofenac when assessed at seven days.
• The benefit persisted for up to twenty-eight days and was related to improvements in stiffness and performance.
• the shortage of blinding of patients and assessors could be a major potential source of bias and diminishes confidence within the results .
• Use of leeches also carries a risk of cellulitis and septicemia thanks to Aeromonas hydrophilia that colonize medicinal leeches.
• A small beneficial effect of whole-body massage employing a Swedish technique was suggested during a pilot study in comparison to wait-listed controls.
It should be noted when reading reports of “complementary” and “alternative” remedies that the consequence may be quite powerful in patients with arthritis. In one preliminary report, for instance, clinical improvement of the maximum amount as 50 percent occurred in up to 45 percent of patients .



At present, I don’t consider that diet or other “complementary” or “alternative” therapies have a job within the routine management of rheumatic diseases.
Nevertheless, examination of the role of diet and other questionable remedies in arthritis reminds us that it’s occasionally salutary to critically reevaluate prevailing notions about therapies.
For antimicrobials, diet, exercise, and maybe others, this reexamination has led to new insights about the pathogenesis and therapy of rheumatic diseases.
We therefore have to balance a healthy skepticism with a willingness to contemplate nontraditional concepts
It is important that we recognize this limitations of science in enabling us to grasp diseases and treat patients.
we should always therefore use caution about being dogmatic in interpreting those notions not thoughtfully scrutinized; however, we should always even be resolute against those ideas we are confident to be false and not questionable, and that we should recognize that the flexibility to differentiate among these possibilities is also difficult. i think that reason will ultimately overcome superstition; as logician wrote, “what science cannot tell us mankind cannot know.”

alternative remedies in rheumatic disorders




The following position has been taken by the American College of Rheumatology (ACR) concerning “complementary” and “alternative” therapies (CAM) for rheumatic diseases:
”The ACR recognizes the interest in CAM modalities.
The ACR supports rigorous scientific evaluation of all modalities that improve the treatment of rheumatic diseases.
The ACR understands that certain characteristics of some CAMs and a few conventional medical interventions make it difficult or impossible to conduct standard randomized controlled trials.
For these modalities, innovative methods of evaluation are needed, as are measures and standards for the generation and interpretation of evidence.
The ACR supports the combination of these modalities proven to be safe and effective by scientifically rigorous clinical trials published within the biomedical review literature.
The ACR advises caution for those not studied scientifically.
The ACR believes healthcare providers should learn about the more common CAM modalities, based upon appropriate scientific evaluation as described above, and may be able to discuss them knowledgeably with patients” .


SUMMARY and proposals

• Clinicians should be aware of the common complementary and alternative remedies available for arthritis to facilitate effective communication with patients and colleagues.
• Therapies are often separated into those which are genuine (ie, those proven acceptably safe and effective), questionable, or ineffective.
• We distinguish between remedies that are mainstream and nonmainstream within the context of usual practice.
• Various factors contribute to the appeal of complementary and alternative remedies.
• These include seeking hope for understanding and a cure or relief from physical and emotional suffering because of the consequences of the medical illness; as a response to psychosocial distress independent of illness severity; as a way of life choice; thanks to difficulty addressing the constraints of medication, and uncertainty concerning outcome.
• The clinician’s response to use of complementary and alternative remedies should include education of the patient and general public, and maintaining communication with the patient regarding these issues.
• We recommend that clinicians mustn’t support the employment of therapies that are generally not considered acceptably safe and effective.
• Potential harms of such therapies include adverse effects, failure to use accepted effective interventions, and financial cost.
• There are a large style of complementary and alternative remedies for rheumatic disorders

Among the more common are:
• Antimicrobial agents
• Special diets or dietary supplements
• Herbal remedies
• Homeopathy, magnets, acupuncture, Ayurvedic medicine, and others
• Special diets or other “complementary” or “alternative” therapies don’t have a job within the routine management of rheumatic diseases.

malnutrition in dialysis

Pathogenesis and treatment of malnutrition in maintenance dialysis

Malnutrition is a crucial problem in patients treated with chronic hemodialysis or peritoneal dialysis.
It occurs in 20 to 70 percent of patients (depending upon the strategy accustomed measure nutritional status), with an increasing length of your time on dialysis correlating with an increasing decline in nutritional parameters.
There could also be significant differences between countries with reference to some measures of nutritional status, like albumen concentration.
Based upon the Dialysis Outcomes and Practice Patterns Study (DOPPS), as an example, the subsequent mean albumen levels were reported in France (3.87 mg/dL), Germany (4.17 mg/dL), Italy (3.98 mg/dL), Spain (3.98 mg/dL), us (3.6 mg/dL), and also the uk (3.72 mg/dL).
However, since differences in measurement methods cause differences in results, the strategy used from laboratory to laboratory and country to country must be known to assess any true differences in albumin in a private patient or groups of patients.

Two important issues are discussed elsewhere:
• How is nutritional status evaluated
• What is that the relation between nutritional status and survival? Patients with malnutrition, as manifested partly by hypoalbuminemia, measured at the onset of or during maintenance dialysis, have an increased fatality rate ( figure 1A-B ).
• this is often true for patients treated with either maintenance hemodialysis or peritoneal dialysis.
• The pathogenesis, prevention, and treatment of malnutrition in these patients are discussed here.
• Most of the observations are made in patients treated with maintenance hemodialysis, but similar considerations apply in many respects to continuous peritoneal dialysis.
The most readily treatable reason for inadequate nutrition in many patients is underdialysis, which might result in anorexia and decreased taste acuity.
Patients with a minimally acceptable Kt/V and a coffee mid-week BUN may appear, initially glance, to be dialyzed.
However, many such patients are underdialyzed with poor protein intake being answerable for the low BUN.
This problem eventually led to the appreciation that protein intake must be considered when evaluating the adequacy of dialysis.
Thus, estimation of the normalized protein equivalence of nitrogen appearance (nPNA), as index of protein intake, may be a a part of the dialysis regimen.
This is also called the normalized protein catabolic rate (nPCR).
The PCR is simply valid as a measure of protein intake within the patient in neutral balance.
The relationship between the dose of dialysis and protein intake was demonstrated in a very small group of hemodialysis patients in whom the intensity of dialysis was increased by enhancing dialysis time, blood flow, and/or membrane extent.
As the Kt/V rose from 0.82 to 1.32 over a 3 month period, there was a concurrent elevation in PCR from 0.81 to 1.02 g/kg per day.
the increase in PCR was indicative of increased protein intake (and better nutrition) due, presumably, to improved appetite.
A second group during which the dialysis regimen was unchanged had no increase in either Kt/V or PCR.
Whether there’s a mathematical link between Kt/V and PCR because they’re both calculated from similar measures could be a subject of debate.
Further support for the observation of improved nutritional intake with increased dialysis dose was reported during a study during which improved weight was observed with more frequent daily hemodialysis.
An increased dialysis dose may additionally enhance nutritional status among malnourished peritoneal dialysis patients.

Even within the well-dialyzed patient, however, variety of things can impair nutrition:
• The presence of an acute, chronic, or occult systemic illness resulting in an inflammatory response may adversely impact nutritional status. Markedly increased energy expenditure, proinflammatory cytokine levels, and oxidative stress appear to produce a link between inflammation and malnutrition.
• Nutrients are lost into the dialysate.
• As an example, aminoalkanoic acid losses into dialysate can average 4 to eight g/day with peritoneal dialysis or hemodialysis.
• With peritoneal dialysis, losses rise much higher during episodes of peritonitis.
• With hemodialysis, certain reuse procedures lead to increased losses of protein into dialysate.
• Protein loss as high as 20 grams in one hemodialysis has been reported with polysulfone dialyzers reused with bleach.
• Dietary restrictions can make food less palatable.
• Furthermore, the encouragement to limit fluid intake to attenuate intradialytic weight gain may result in a concurrent decrease in caloric intake.
• Solid food contains a high fluid content and lots of beverages contain a considerable amount of calories.
• The dialysis procedure itself could also be catabolic, thanks to reduced protein synthesis and also the loss of amino acids in dialysate; this effect could also be more prominent with bioincompatible membranes.
• This may be overcome with appropriate nutritional intake.
• As shown in some, but not all, studies, persistent acidosis may enhance protein degradation and aminoalkanoic acid oxidation.
• Gastroparesis (by slowing gastric emptying) or, in peritoneal dialysis, the presence of dialysate within the abdomen may impart a sense of fullness.
• Some medications, like phosphate binders, can impair nutrient absorption.
• Adequate dialysis isn’t a whole substitute for the clearance functions of an intact kidney. specifically, the retention of middle molecules (1000 to 5000 Daltons) may partially contribute to anorexia, possibly by directly affecting the central systema nervosum.
• Serum concentrations of leptin, a hormone that induces satiety via effects upon the hypothalamus, could also be increased thanks to reduced renal or dialysis clearance.
• However, a job for leptin in malnutrition within the dialysis patient remains to be proven.
• Chronic volume overload could also be directly related to malnutrition, with improved fluid status increasing overall nutritional status.
• The presence of both malnutrition and intensely low levels of renal function at the time of dialysis initiation are directly related to subsequent poor nutritional status despite adequate dialysis.
• This observation suggests that dialysis should be begun before the onset of serious malnutrition.


• The commencement within the prevention of malnutrition is careful assessment of the patient’s nutritional status at the start of dialysis and each three to 6 months thereafter.

• Early diagnosis and correction can avoid clinical deterioration which will make the patient harder to treat, partially because malnutrition itself may cause anorexia.

• This relationship is recommended by studies within which improved nutritional status led to improved food intake.

• In one report, for instance, malnourished patients on hemodialysis received parenteral nutrition supplements during the dialysis procedure.

• This led to a rise in food intake, which began before any changes can be demonstrated in nutritional status.
Ingestion of an adequate diet is incredibly important if malnutrition is to be prevented. Patients previously on a low-protein diet might have to be reminded to extend protein intake once dialysis begins to counteract protein loss within the dialysate.
Although somewhat controversial, a diet providing 1.0 to 1.2 g/kg per day of high biologic value protein is usually recommended for patients on hemodialysis.
Continuous ambulatory peritoneal dialysis is related to a better level of dialysate protein loss; as a result, protein intake should be a minimum of 1.2 g/kg per day with this treatment modality.
One study demonstrated that the metabolic response to protein intake is normal in hemodialysis patients, further supporting the importance of maintaining adequate dietary protein intake.
Adequate caloric intake also must be emphasized, since it’s required for anabolism.
In one study, for instance, patients on maintenance hemodialysis were studied on different diets.
There was negative balance unless caloric intake was a minimum of 32 kcal/kg ideal weight
For patients treated with peritoneal dialysis, the calories provided by the dialysis solution should be taken under consideration.

The presence of malnutrition is sometimes suspected from anthropometry or the presence of hypoalbuminemia or decreased creatinine production.
Evaluation should begin with an intensive history to see whether the reduction in food intake is caused by unpalatable dietary restrictions or by changes within the patient’s sense of taste.
The dietary history should include personal or ethnic food preferences.
If limiting such preferences is interfering with food intake, the clinician or dietitian should work with the patient and family to feature more preferred foods to the diet. In cases of severe malnutrition, most or all dietary limitations may must be removed for a limited period of your time.
In general, if malnutrition is diagnosed, we advise the subsequent stepped treatment strategy:
• Evaluation of any source of inflammation should be sought and managed.
• Dietary intake should be assessed and dietary counseling should be undertaken.
• If the patient cannot improve nutrient intake by diet alone, intake should be improved in a very step-wise fashion, starting with oral supplements and ending with total parenteral nutrition if no other nutrient intake methodology is suitable.

Drug toxicity
Drugs that may impair appetite or make meals less palatable should be reduced or eliminated.
In severe cases, the patient may have the benefit of temporary cessation of oral phosphate binders.
Hyperphosphatemia may be a lesser risk during this setting, since the low protein intake itself will lower the plasma phosphate concentration.
In fact, hypophosphatemia is also an extra clue to the presence of malnutrition.
Gastroparesis may be contributing factor to decreased food intake by delaying gastric emptying, thereby increasing the sensation of fullness.
This complication is most typical in diabetics (possibly affecting as many as 20 to 30 percent of diabetics with end-stage renal disease), but can even occur in nondiabetics.
If gastroparesis is suspected from the history, the speed of gastric emptying may be accurately assessed by various methods, like ingestion of a radiolabeled test meal with simultaneous gastric scanning.
If slow or delayed gastric emptying is documented, several therapeutic modalities is also beneficial:
• Metoclopramide are often given, but the dose must be limited in patients with end-stage renal disease.
• Patients are successfully treated with erythromycin
• Patients not awake to erythromycin may answer other agents, like cisapride.
• However, the utilization of cisapride is now restricted per the manufacturer’s and Federal Drug Administration’s recommendations thanks to the chance of arrhythmias.
• As of August 2000, prescriptions for the drug can only be filled directly through the manufacturer after providing documentation on need for the drug and assessment of risk factors for cardiac arrhythmias within the individual patient (including a protracted QTc on the EKG or use of medicines known to change the drug’s metabolism like macrolide antibiotics, antifungals and phenothiazines).
If gastroparesis is detected via gastric emptying scans, the optimal therapeutic agent is also chosen based upon the prokinetic response to an intravenous test dose.
As an example, the gastric emptying response to intravenous doses of metoclopramide (5 mg) and erythromycin (200 mg) was assessed in 6 dialysis patients with hypoalbuminemia and occult gastroparesis.
Subsequent oral therapy based upon a successful gastric response significantly improved albumen levels (from 3.3 to 3.7 g/dL).
Nutritional supplements
If attention to the preceding problems doesn’t improve appetite and food intake, then nutritional supplementation could also be necessary.
Oral supplementation, enteral tube feeding, and parenteral nutrition are all possibilities.
A 2005 systematic review and meta-analysis of 18 studies (including five randomized controlled trials) found that enteral nutritional support increased total intake and albumin concentration (0.23 g/dL).
Clinical outcomes were evaluated in precisely some studies, while data was inadequate to check both disease-specific versus standard formulae and enteral versus parenteral nutrition.
Oral supplements are the simplest and cheapest to use.
Several supplements are intended primarily for the patient with end-stage renal disease.
They are low in potassium and fairly dense in nutrients, thereby providing adequate calories and protein, while minimizing the danger of hyperkalemia and fluid overload.
However, these supplements have the disadvantage of being more costly than less specific preparations, thereby making compliance a difficulty.
Oral supplements provided at the time of dialysis treatments could also be an efficient therapy.
This was suggested by a matched cohort study of maintenance hemodialysis patients with albumin concentrations ≤3.5 g/dL who were given oral nutritional supplements at the time of dialysis.
By 15 months of follow-up, improved survival was demonstrated among patients given oral nutritional supplements compared with untreated matched control patients by both as-treated and intention-to-treat analysis. the best advantage of oral supplements was observed among patients with rock bottom baseline albumen concentration (≤3.2 g/dL).
These observations, although potentially clinically significant, are limited by the absence of random allocation of patients; although control patients were matched by propensity score, residual confounding remains possible.
Another study analyzed the effect of providing oral supplements (taken at non-dialysis times) to patients with albumin ≤3.8 mg/dL.
This was a retrospective analysis of knowledge provided by Fresinius Medical Health Care Plan’s disease management program, during which eligible patients (ie, defined as those with albumin ≤3.8 mg/dL for 2 or more months) were given 24 cans of oral supplement per month.
Among eligible patients, 276 received supplements and 194 failed to, either because it absolutely was deemed inappropriate for unspecified reasons, or because they refused.
After multiple adjustments, compared with no supplements, the employment of oral supplements was related to a lower rate of hospitalization (89 versus 68 percent respectively), and with a nonsignificant trend toward improved survival at one year (p = 0.09).
This study was limited by the possible presence of unadjusted differences within the patient populations.
Despite the constraints related to both studies cited above, oral nutritional supplements administered during the dialysis treatment is also a useful intervention for a few patients with very low albumen.
Compared with intravenous nutritional supplementation, oral supplementation has fewer side effects, is cheaper, and appears to be an affordable start within the nutrition management of those patients.
The general supplements will be tried in patients ready to tolerate the rise in potassium and fluid intake.
We limit the precise “renal failure” supplements to patients with preexisting hyperkalemia or fluid overload due, for instance, to failure. Although some evidence suggests that oral essential amino acids is also modestly beneficial to patients with significant hypoalbuminemia, further study is required before any recommendation concerning their use.
Patient compliance is vital to the success of oral nutrient supplements.
A different regimen is required in patients with severe anorexia who are unable to extend their oral intake.
Overnight supplementation by nasoenteral feeding tube could also be effective during this setting.
A short course of overnight tube feeding can result in a sufficient improvement in nutritional status and overall well-being that adequate dietary oral is resumed.
Patients with severe gastroparesis could also be unable to tolerate any kind of oral supplementation.
Intradialytic parenteral nutrition (IDPN) could also be beneficial during this setting if the malnutrition isn’t too severe. IDPN solutions are similar those used for total parenteral nutrition : a typical solution contains 10 percent amino acids and 40 to 50 percent glucose, 10 to twenty percent lipids, or a mix of carbohydrate or lipids depending upon the wants of the patient.
However, IDPN has certain limitations:
• It is that the costliest and least efficient nutritional supplement. IDPN often costs twice the maximum amount as dialysis itself, and only 70 percent of the nutrients are literally delivered to the patient due to loss into the dialysate.
• Malnutrition may persist, since IDPN is run only three days per week for roughly 4 hours.
• It could also be related to a below expected delivered dose of dialysis, due possibly to increased urea generation.
Despite these shortcomings, IDPN is convenient (because it’s delivered during dialysis) and is probably going to be beneficial in some patients.
However, although variety of studies suggest that IDPN provides substantial benefit, most were case reports, retrospective, or poorly designed.
To better assess the consequences of IDPN, 186 malnourished hemodialysis patients were randomly assigned to oral nutritional supplements, with or without one year of IDPN.
At two years, there was no difference in mortality, hospitalization rate, and nutritional status between the 2 groups.
With statistical procedure, however, improved nutrition defined as a rise in prealbumin level of greater than 30 mg/L within the primary three months correlated with an approximately 50 percent decrease in mortality at two years.
The optimal indications for IDPN haven’t been established.
We consider use of this modality within the malnourished dialysis patient who cannot tolerate oral supplements but who can consume a minimum of 50 percent of the prescribed caloric intake.
This is in step with the 2007 European best practice guidelines for hemodialysis.
If this degree of oral intake can not be reached, we first try a nasoenteral feeding tube with nighttime enteral nutrition or, if oral intake isn’t tolerated, the institution of total parenteral nutrition should be considered.
Total parenteral nutrition (TPN) is required within the rare patient with severe malabsorption, severe malnutrition, or severe intolerance of oral supplements. Although generally well tolerated, TPN solutions typically contain added potassium, phosphorus, and magnesium.
Thus, patients with end-stage renal disease receiving TPN are in danger for the event of hyperkalemia, hyperphosphatemia, and hypermagnesemia. Elimination of the added electrolytes can prevent these problems but carries the reverse risk of electrolyte deficiencies with prolonged therapy.
We generally recommend that TPN be started with solutions containing little or no added electrolytes.
The patient should then be carefully monitored, and electrolytes should be added if the plasma levels fall below the conventional range.
Dialysis prescription
The dialysis prescription should be reassessed in terms of Kt/V and also the protein catabolic rate.
In a trial to handle the question of optimal dialysis dose and membrane flux for hemodialysis patients, an oversized test, called the Hemodialysis (HEMO) Study, was performed.
Patients were randomly assigned to a regular (single-pool Kt/V of 1.25) or high dose of dialysis (single-pool Kt/V of 1.65) and a low- or high-flux dialyzer.
Similar outcomes in terms of survival were observed with high and standard dialysis doses likewise as dialysis using high and low flux membranes.
Subsequent analysis of the HEMO trial also found that nutritional parameters, like albumin and anthropometric measures, were the identical with the various dose and flux interventions.
Current minimum recommendations are 1.3 to 1.4 for Kt/V in hemodialysis, at least 1.7 for weekly Kt/V in continuous ambulatory peritoneal dialysis, and 1.0 to 1.2 g/kg per day for the nPNA.
there’s also some preliminary evidence that, compared with Kt/V, Kt alone (which is that the non-normalized dialysis dose) could also be more closely related to albumen levels.
Although further study is required, daily in center and nocturnal hemodialysis are used as a rescue therapy for patients with severe malnutrition complicating uremia, with patients generally reporting increased appetite after switching from conventional to daily dialysis.
The effects on nutrition of short daily and nocturnal hemodialysis are presented separately.
Recombinant human STH
Some studies suggest that administration of recombinant human somatotropic hormone can reduce wasting and catabolism, improve nutritional status, and lower the BUN in hemodialysis patients, even within the elderly.
• In one study, 139 adult dialysis patients with albumin levels but 4 g/dL were randomly assigned to 6 months of therapy with different doses of recombinant somatotrophin or placebo.
• Lean body mass significantly increased in the least dose levels (2.5 kg versus –0.4 kg) for placebo, while albumen levels attended increase.
• In another prospective, cross-over study, improvements in protein metabolism were observed with administration of recombinant human somatotropin in comparison to no hormone therapy, as shown by a decrease in BUN (55 versus 40 mg/dL [19.6 versus 14.3 mmol/L]) and a decrease in protein catabolic rate (0.82 versus 0.67 g/kg per day). Follow-up evaluation of those patients revealed that the improved protein metabolism resulted from the increased ability to utilize essential amino acids. Similar improvements in protein metabolism were noted in other studies during which the like recombinant human STH could largely be explained by a rise in free insulin-like growth factor-1 levels.
Recombinant human endocrine has also been reported to boost nutritional status in malnourished patients on hemodialysis treated with IDPN; the latter was ineffective when given alone.
Recombinant insulin-like growth factor-1 (IGF-1) has also been shown to markedly increase balance in patients treated with CAPD.
Despite evidence suggesting that recombinant human somatotrophic hormone provides short term benefits ,significant long-term nutritional benefits with this agent aren’t consistently observed.
additionally, the consequences of recombinant human human growth hormone on malnutrition associated morbidity and mortality are unclear.
One additional major limitation of the utilization of recombinant therapy for the treatment of malnutrition in patients with ESRD is its very high cost.
To best assess the advantages and adverse effects related to recombinant human somatotropic hormone , the chance trial will assess the effect of this hormone on survival in hypoalbuminemic dialysis patients and its effect upon morbidity, markers of body protein mass, inflammation, exercise capacity, and quality of life.
Correction of acidosis
Uremic acidosis can increase muscle breakdown and diminish albumin synthesis, resulting in muscle wasting and muscle weakness.
Recommendations concerning correction of acidosis are presented separately.

Androgenic anabolic steroids and anti inflammatory drugs are utilized in dialysis patients with malnutrition.
• Only limited data have evaluated the efficacy and adverse effects of androgenic anabolic steroids in dialysis patients.
• Although a rise in weight, muscle mass, and albumin are reported, the long-term efficacy and risk for adverse effects with these agents is unclear. These agents therefore can not be recommended during this setting.
• The use of anti-inflammatory agents in patients with malnutrition-inflammation syndrome complex is reviewed separately.
• Dialysis patients often have decreased taste acuity, which is controversially related to deficiency disease.
• If present, diminished taste acuity can result in decreased intake and anorexia.
• The role of deficiency disease has never been established and that we don’t routinely measure plasma zinc levels or administer zinc supplements.
Much of the foregoing discussion applies to both hemodialysis and peritoneal dialysis.
As previously noted, however, there are several problems unique to peritoneal dialysis, including increased dialysate protein losses and a sense of fullness because of dialysate within the abdomen.
Gastroparesis is additionally more common, since many CAPD patients are diabetic.
The management of malnutrition in these patients again focuses on prevention and treatment.
The approach is comparable thereto noted above, but there are variety of specific recommendations:
• Patients with loss of appetite should drain the dialysate just before meals in order that the abdomen is empty at mealtime.
• They may additionally tolerate frequent, small meals better than the standard three large meals.
• Peritoneal dialysis patients generally have fewer dietary restrictions than those treated with hemodialysis, since they’re continuously dialyzed. However, some patients consume excessive amounts of fluid that are removed by the utilization of high-dextrose dialysate. the following increase in glucose absorption can, in susceptible subjects, cause hyperglycemia, which might directly suppress appetite.
• Avoidance of excess fluid intake is therefore desirable, since it limits the requirement to be used of hypertonic dialysis solutions.
• Persistent malnutrition is treated with oral supplements or TPN. Limited data, however, have reported mixed results with oral nutritional supplementation; this can be possibly the results of poor compliance, small sample size, and reliance upon albumen concentration because the principal outcome measure.
• Clearly, IDPN isn’t feasible thanks to continuous dialysis.
Amino acid dialysate
Dialysate containing amino acids because the osmotic agent, instead of glucose, may minimize a number of these above problems, increasing net protein intake, allowing the attainment of positive balance and net anabolism and improving the plasma albumin concentration and overall nutrition.
In a prospective three month study, 105 malnourished peritoneal dialysis patients were randomly assigned to 1 or two exchanges per day with a 1.1 percent organic compound dialysate, or to usual therapy.
Benefits observed within the group receiving the protein dialysate included increases in insulin-like growth factor-1, and reduces in serum potassium and inorganic phosphorus, findings indicative of a general anabolic response.
The combination of organic compound plus glucose dialysate might also improve the nutritional status of malnourished patients. in a very random order crossover study of eight patients undergoing nocturnal automated peritoneal dialysis, protein kinetics was markedly superior over a 1 week period with dialysate containing organic compound plus glucose versus that observed during every week with the control dialysate.
Further study in a very larger number of patients is required to adequately evaluate this approach.
Dialysate containing amino acids because the osmotic agent is now commercially available in Europe, Canada and other regions, although they’re not commercially available within the us.
Patients who are treated with aminoalkanoic acid containing dialysate should be monitored closely for the subsequent reasons:
• To avoid aminoalkanoic acid imbalance, organic compound dialysate mustn’t be used for over one or at the most two exchanges per day.
• As the osmotic agent, a 1.1 percent solution of amino acids has an ultrafiltration profile kind of like dialysis solutions containing 1.5 percent dextrose.
• Thus, aminoalkanoic acid dialysate mustn’t be used for the overnight dwell because most of the amino acids are absorbed, thereby limiting the degree of fluid removal.
• There is concern that amino acids will raise urea nitrogen appearance and urea production if they’re not used for anabolism.
• organic compound dialysate may result in acidosis which is primarily thanks to the proton contained in cationic amino acids (such as lysine).
• Thus, both the BUN, and plasma bicarbonate concentration should be monitored.
The European Best Practice Guidelines suggest that an aminoalkanoic acid containing solution should be considered in malnourished patients.
They also state that this solution should only be used once daily.
Malnourished patients who don’t tolerate oral supplements are possibly to profit.
A response — improved appetite, increased plasma albumin concentration, weight gain — should be seen within three months; at now, we switch back to traditional dialysate.

Enteral tube feeding
Some PD patients with malnutrition who are unable to ingest adequate amounts of nutrition are successfully treated with enteral tube feedings, particularly with gastrostomy or gastrojejunostomy tubes.
A paucity of knowledge exists concerning the utilization of this method of feeding in adults, but it appears to end in improved nutrition in malnourished children.

Limited evidence suggests that improved control of acidosis may enhance the nutritional status in peritoneal dialysis patients.
In one study, 200 consecutive patients initiating peritoneal dialysis were randomized to high (lactate of 40 meq/L) or low (35 meq/L) alkali dialysate for one year.
Correction of acidosis with carbonate and sodium hydrogen carbonate was also utilized within the high alkali group.
At one year, the serum bicarbonate within the high alkali group was 27 meq/L versus 23 meq/L within the low alkali group.
Compared to the low alkali group, benefits observed with high alkali therapy included a greater increase in weight (6.1 versus 3.7 kg, P<0.05) and lower morbidity (16.4 versus 21.2 days spent within the hospital, P<0.05).
A preliminary study found that administration of ghrelin, a hormone that functions as an appetite enhancer, may enhance food intake acutely in malnourished patients undergoing peritoneal dialysis.
Longer term study is required to higher characterize the consequences of ghrelin during this setting.

UpToDate offers two sorts of patient education materials, “The Basics” and “Beyond the fundamentals.
” the fundamentals patient education pieces are written in plain language, at the 5 th to six th grade reading level, and that they answer the four or five key questions a patient might need a couple of given condition.
These articles are best for patients who need a general overview and preferring short, easy-to-read materials.
Beyond the fundamentals patient education pieces are longer, more sophisticated, and more detailed.
These articles are written at the ten th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to the present topic.
We encourage you to print or e-mail these topics to your patients.
(You may also locate patient education articles on a spread of subjects by searching on “patient info” and also the keyword(s) of interest.)
• Basics topic

• SUMMARY and proposals

• Malnutrition is common in patients treated with maintenance dialysis. Principal causes include inadequate dialysis dose, inflammation, dietary restrictions, nutrients lost via dialysate, catabolic properties of dialysis, and other factors.
• The beginning within the prevention of malnutrition is careful assessment of the patient’s nutritional status at the start of dialysis and each three to 6 months thereafter.
• Ingestion of an adequate diet is incredibly important if malnutrition is to be prevented.
• If malnutrition is diagnosed, it’s important to undertake treatment strategies as follows:
• Evaluation of any source of inflammation should be sought and managed.
• Dietary intake should be assessed and dietary counseling should be undertaken.
• If the patient cannot improve nutrient intake by diet alone, intake should be improved during a step-wise fashion, starting with oral supplements and ending with total parenteral nutrition if no other nutrient intake methodology is acceptable.
• Much of the discussion associated with malnutrition during this topic review applies to both hemodialysis and peritoneal dialysis.
• However, since there are several problems unique to peritoneal dialysis, variety of specific recommendations may be made in these patients.
m 50 words

Adult nutrition


Aging is characterized by diminished organ system reserves, weakened homeostatic controls, and increased heterogeneity among individuals, influenced by genetic and environmental factors.

Nutritional needs of the older individual are determined by multiple factors, including specific health problems and related organ system compromise; a human level of activity, energy expenditure, and caloric requirements; the flexibility to access, prepare, ingest, and digest food; and private food preferences.

This topic will discuss assessment of nutrition within the older adult, still because the etiology, evaluation, and treatment of weight loss, overnutrition, and specific common nutrient deficiencies. Related problems with geriatric health maintenance and nutritional assessment are discussed separately.

Data from studies of acute hospitalization in older patients suggest that up to 71 percent are at nutritional risk or are malnourished.
Malnutrition is related to increased mortality risk. the subsequent criteria for the diagnosis of malnutrition are recommended in an exceedingly consensus statement from the Academy of Nutrition and Dietetics (Academy) and also the American Society for Parenteral and Enteral Nutrition (ASPEN):
Two or more of the subsequent six characteristics:
• Insufficient energy intake
• Weight loss
• Loss of muscle mass
• Loss of subcutaneous fat
• Localized or generalized fluid accumulation which will mask weight loss
• Diminished functional status as measured by handgrip strength.


Serial measurements of weight offer the best screen for nutritional adequacy and alter in nutritional status in older adults.

Obtaining periodic body weights could also be challenging, particularly in frail patients. A chair or bed scale that’s regularly calibrated could also be needed for patients who cannot stand on an upright exerciser scale. Low weight is defined as <80 percent of the recommended weight .

Weight loss
Studies suggest that weight loss in older adults, especially if it’s not volitional, is predictive of mortality. Loss of as little as 5 percent of weight over a 3 year period is related to increased mortality among community-dwelling older adults .

Weight loss for those with a BMI below 30 likely poses a greater mortality threat to older adults than not losing weight or of getting a BMI of 25 to 30.

However, obesity (BMI ≥30) continues to own a negative impact on morbidity and mortality in older adults. The relative good thing about intentional weight loss in obese older adults with osteoarthritis, impaired activity tolerance, DM, and coronary heart condition, especially when combined with exercise, is becoming increasingly apparent .

Weight loss is taken into account to be clinically significant with the subsequent parameters
• ≥2 percent decrease of baseline weight in one month
• ≥5 percent decrease in three months, or
• ≥10 percent in six months
In the long run care setting, a clinically significant weight loss episode is defined by the long run care Minimum Data Set (MDS) as loss of 5 percent of usual weight in 30 days, or 10 percent in 6 months.

Screening tools
variety of screening tools are developed for identifying older adults in danger for poor nutrition.

• The Nutritional Risk Screening (NRS) 2002 has two components: a screening assessment for undernutrition and an estimate for disease severity. Undernutrition is estimated with three variables: BMI, percent recent weight loss, and alter in food intake . Disease severity ranges from a score of zero (for those with chronic illnesses or a hip fracture) to a few (for those within the ICU with an APACHE score of 10). In hospitalized patients, the NRS 2002 showed a sensitivity of 39 to 70 percent and a specificity of 83 to 93 percent when put next to the Mini Nutritional Assessment and therefore the Subjective Global Assessment .
• The Simplified Nutrition Assessment Questionnaire (SNAQ), a four item screener, was tested in community-dwelling older adults and long-term care residents . In those populations, it had a sensitivity and specificity of 88.2 and 83.5 percent, respectively, for identification of older persons in danger for five and 10 percent weight loss, respectively ( figure 1 ).
• SCREEN II (Seniors within the Community: Risk Evaluation for Eating and Nutrition) may be a 17-item tool that assesses nutritional risk by evaluating food intake, physiological barriers to eating (difficulty with chewing or swallowing), weight change, and social/functional barriers to eating. The tool has excellent sensitivity and specificity, yet as interrater and test/retest reliability .An eight-question abbreviated version of SCREEN II is additionally available .
• The Malnutrition Universal Screening Tool (MUST) incorporates BMI, weight loss in three to 6 months, and anorexia for five days thanks to disease. it’s commonly utilized in the uk and is especially sensitive for recognition of protein energy undernutrition in hospitalized patients .
• The Malnutrition Screening Tool (MST) was developed to be used in acutely hospitalized patients and also validated to be used in cancer patients (average age 57 to 60 years, range 15 to 89) . It asks two simple questions: “Have you been eating poorly due to a decreased appetite?” and “Have you lost weight recently without trying?” The sensitivity of the MST in hospitalized patients ranges from 74 to 100% with a specificity of 76 to 93 percent compared to the Subjective Global Assessment.
• The Mini Nutritional Assessment (MNA) consists of a world assessment and subjective perception of health, moreover as questions specific to diet, and a series of anthropomorphic measurements ( figure 2 ) .It has been widely validated and is predictive of poor outcomes .The Mini Nutritional Assessment-Short Form uses six questions from the total MNA and may substitute calf circumference if BMI isn’t available. A validation study demonstrated good sensitivity compared to the total MNA.
The two screening tools within the highest quartile for sensitivity (>83 percent) and specificity (>90 percent) were the MNA (SF) and therefore the MST.

The prevalence of malnutrition in older adults relies upon the population studied, varying by geography, age distribution, and living situation. A review of results of the Mini Nutritional Assessment across settings and countries in Europe, the u. s. and African nation, found the prevalence of malnutrition among 4507 people (mean age 82.3, 75.2 percent female) was 22.8 percent Highest rates were within the rehabilitation setting (50.5 percent) and lowest among community dwellers (5.8 percent).
Over a 3rd of hospitalized older adults (38.7 percent) during this study met the standards for malnutrition.
Compared to younger adults, undernutrition in older individuals is both more common and should have greater impact on outcomes, including physical function healthcare utilization, and length of stay for surgical hospitalizations
Inadequate energy intake is common in hospitalized older adults, with increased risk related to poor appetite, higher BMI, diagnosis of infection or cancer, delirium, and want for assistance with feeding .Some studies suggest that older adults are less ready to adapt to underfeeding.
One study found that, following a period of experimental underfeeding, older adults experienced less frequent hunger than younger adults, and didn’t regain the whole amount of weight they’d lost when allowed to consume food freely for 6 months while on the average younger adults regained all their lost weight.
In contrast, the same study didn’t demonstrate age differences in ad lib intake, anthropometric indices, gastric emptying rate, and cholecystokinin levels in blood after a period of underfeeding and so consumption of food freely
The lack of ability to catch up on periods of low food intake because of illness or other difficulties may end up in long-term, persistent weight changes, especially when combined with social, medical, or psychological factors which will negatively impact weight.
Involuntary weight loss is driven by:
• Inadequate dietary intake
• Appetite loss (anorexia)
• Disuse or muscle atrophy (sarcopenia)
• Inflammatory effects of disease (cachexia)
or a mixture of those factors.
Inadequate dietary intake
There are multiple causes of weight loss because of inadequate nutrient intake.
These include social (eg, poverty, isolation), psychological (eg, depression, dementia), medical (eg, edentulism, dysphagia), and pharmacological issues.

Social factors
Social factors contributing to weight loss include:
• Increased likelihood of isolation at mealtimes. One third of persons over 65, and half over 85 live alone, which usually decreases food enjoyment and calorie intake. Several studies have demonstrated that older adults who eat the presence of others consume quite those that eat alone.

• Financial limitations affecting food acquisition. A greater proportion of older adults live near the personal income, compared to the overall population. Individuals with fixed incomes may use money previously spent on food for medications and other needed items.

Medical and psychiatric factors
The most important medical and psychiatric causes of weight loss in older adults are malignancy and depression.
• Malignancy was identified because the cause for weight loss in 9 percent of older patients during a study of medical outpatients, and was second to depression because the most frequent identifiable reason for undernutrition .
• In another study of unexplained weight loss in 45 ambulatory older adults, the foremost common identified cause for weight loss was depression (18 percent), again followed by malignancy (16 percent).

• a 3rd report found cancer, predominantly of the digestive tube, as a reason for weight loss in 36 percent of the 154 patients evaluated .

• Depression and dysphoria are common in older adults and infrequently remain unrecognized and undertreated. Depression is a very important reason behind weight loss within the subacute care and home settings, furthermore as in older patients within the community.

• during a chart review of 1017 medical outpatients, as an example, depression was the explanation for weight loss in 30 percent of the older patients, compared to only 15 percent in younger patients .

• Dysphagia is present in approximately 7 to 10 percent of the older adult population and encompasses a negative effect on energy intake .

• Dysphagia occurs in about one half patients with acute first-ever stroke or with Parkinson disease .

• Oropharyngeal dysphagia may occur thanks to stroke, Parkinson disease, amyotrophic lateral sclerosis, Zenker’s diverticula, and other motility or structural disorders. Esophageal dysphagia are often thanks to motility problems (eg, achalasia, diffuse esophageal spasm, scleroderma) and structural issues.

Other important medical etiologies to contemplate include:
• Endocrine disorders (hyperthyroidism, new onset diabetes mellitus)
• End organ disease (congestive heart disease, end stage renal disease, chronic obstructive pulmonary disease, hepatic failure)
• Gastrointestinal disorders (celiac disease, ischemic bowel, inflammatory bowel disease, pancreatic insufficiency, ulceration disease, GERD)
Infections (tuberculosis)
• Rheumatologic disorders (polymyalgia rheumatica, arthritis)
• Neurological conditions (Parkinson disease, chronic pain)
• Alzheimer’s disease (especially among those with behavioral and psychological symptoms)
• Drug or alcohol dependence
• Medication side effects ( digoxin , opioids, serotonin-reuptake inhibitors, diuretics, and topiramate )
Additionally, medical or dental conditions in older adults may impair the flexibility to eat.
Paralysis from stroke, severe arthritis, hand tremors, and dementia may result in routine need for feeding assistance from others.

Chewing difficulty puts older adults in danger for poor intake. in a very study of non-institutionalized older adults, edentulousness doubled the chance for significant weight loss over a one-year period, after adjusting for gender, income, age, and baseline weight .

Physiologic factors
Physiologic factors related to weight loss include age-related decrease in taste and smell sensitivity, delayed gastric emptying, early satiety, and impairment within the regulation of food intake.
• Age raises the brink for odor detection and lowers perceived odor intensity .
• The number of taste buds remains constant, but thresholds for recognition of salt and other specific tastes increase.
• Impaired taste and smell likely alter the cephalic phase of digestion, affecting learned associations between the taste and smell of food with signals involved in meal initiation, volume of food intake, and meal termination.

• Decrease within the rate of gastric emptying in older adults may lead to prolonged antral distension with reduced hunger and increased satiety .

• Aging may influence production of, and/or CNS sensitivity to, several digestive hormones thought to be involved in satiety.

• Glucagon, glucagon-like peptide-1 (GLP-1), cholecystokinin (CCK), leptin, and ghrelin are peripheral satiety signals and appear to be less well detected by the brain with increased age .

• Causes of impaired regulation of food intake include decreased stimulatory effects of neurotransmitters involved in appetite (eg, opioids, neuropeptide Y, the orexins and ghrelin) and increased sensitivity to the inhibitory effects of corticotropin-releasing factor, serotonin, and cholecystokinin.

Anorexia, the decrease in appetite, in older adults is influenced by multiple physiological changes.
Food intake gradually diminishes with age .
Much of the intake reduction in early adulthood is an appropriate response to decreased energy needs because of reduced physical activity, decreased resting energy expenditure (REE), and/or loss of lean body mass.

Changes in taste and smell result in a decreased desire to eat and early satiety develops with age, associated with gastrointestinal changes and gastric hormone changes, as discussed above.

Appetite regulation is further tormented by illness, drugs, dementia, and mood disorders. In 292 older adults from assisted living facilities or senior centers, fair to poor emotional well-being was most closely related to poor appetite (OR 5.60, 95% CI 2.60-12.07) .

Cachexia has been defined as a “complex metabolic syndrome related to underlying illness, and characterized by loss of muscle with or without loss of fat mass” .
It is related to increased morbidity.
Anorexia, inflammation, insulin resistance, and increased muscle protein breakdown are frequently related to cachexia.

Cachexia is distinct from starvation, age-related loss of muscle mass, or psychiatric, intestinal, or endocrinologic causes of weight loss.
Cachexia involves many dysregulated pathways, resulting in an imbalance between catabolism and anabolism.
Because of the presence of underlying inflammation and catabolism, cachexia often is proof against nutritional intervention.
Cachexia usually occurs within the setting of underlying illness involving a cytokine-mediated response. Such illnesses include cancer, end-stage renal disease, chronic pulmonary disease, congestive cardiopathy, rheumatoid arthritis, and AIDS.

Pro-inflammatory cytokines commonly involved in cachexia include interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor-a (TNF-a) .
These cytokines contribute to lipolysis, muscle protein breakdown, and nitrogen loss, additionally to producing anorexia.
They augment the acute phase response, up-regulate the assembly of CRP and down-regulate the transcription of albumin .

In a study of older Framingham Heart Study participants, levels of insulin-like protein 1 (IGF-1) and muscle mass decreased, whereas interleukin 6 levels increased, with age .
These changes appear to occur even within the absence of overt disease, suggesting that a subclinical inflammatory process is also a part of normal aging.
Although elevated pro-inflammatory cytokines (especially IL-1, IL-6 and TNF-a) are commonly seen in older adults, levels are higher in those with cachexia.

Sarcopenia may be a syndrome characterized by the loss of muscle mass, strength, and performance .
Low muscle mass is defined as a decrease in appendicular muscle mass two standard deviations below the mean for young healthy adults , and is sometimes measured by DEXA or bio-electrical impedance in clinical practice.
Unlike cachexia, sarcopenia doesn’t require the presence of an underlying illness.
Also, whereas the majority with cachexia are sarcopenic, most sarcopenic individuals don’t seem to be considered cachectic .
Sarcopenia is related to increased rates of functional impairment, disability, falls and mortality .
The causes of sarcopenia are multifactorial and might include disuse, changing endocrine function, chronic diseases, inflammation, insulin resistance, and nutritional deficiencies .

Sarcopenia was identified in 53 to 57 percent of men, and 43 to 60 percent of ladies, over the age of 80 in one study.
Loss of muscle mass, in the course of decreased muscle strength, can occur in overweight individuals (sarcopenic-obese) additionally as in normal and underweight individuals.

Causes of sarcopenia include endocrine changes, activation of proinflammatory cytokines, reduced alpha motor units within the medulla spinalis, decreased physical activity, and suboptimal protein intake.
• Reductions in testosterone and estrogen that accompany aging appear to accelerate the event of sarcopenia .

• Relative deficiencies of estrogen and testosterone contribute to muscle catabolism and promotion of catabolic cytokines like IL-1 and IL-6 .
Testosterone replacement may increase muscle mass, but studies haven’t demonstrated similar benefit for estrogen replacement.
• Insulin resistance increases with age.
• Insulin inhibits muscle breakdown and therefore the reduction of insulin action on muscle may contribute to muscle catabolism .
• Physical activity declines with age. within the u. s., 28 to 34 percent of adults aged 65 to 74 and 35 to 44 percent of adults ages 75 or older are inactive .
• Inactivity exacerbates ongoing muscle loss and increases proportion of body fat mass .
• Inadequate protein intake may also contribute to sarcopenia. in an exceedingly small randomized study of postmenopausal women, consumption of inadequate dietary protein (0.45 g/kg/d) compared to adequate intake (0.92 g/kg/d) for 6 weeks led to deterioration in strength and lean body mass. In one US survey, over 10 percent of adults over age 60 within the US consumed but this RDA for protein .

A study within the uk of 2983 men and ladies aged 59 to 73 years found an independent correlation between increased grip strength and consumption of fatty fish .
The speculation is raised that the anti-inflammatory properties of omega-3-fatty acids is also an element in prevention of sarcopenia.

Recommendations vary on the degree of weight loss, and also the period of your time for weight loss, that ought to prompt clinical investigation.
One commonly accepted definition for clinically important weight loss is loss of 4 to five percent of total weight over 6 to 12 months.
Unintentional weight loss should result in clinical concern no matter whether the patient is overweight at baseline. Whether or not intentional weight loss is of concern remains a matter of some speculation.

Initial evaluation
the subsequent steps are suggested within the initial evaluation of an older one who is noted to own lost weight, or for whom concern is raised about weight loss by the patient, relations, or caregivers.
• Document the load loss.
• While it’s important to notice objective evidence of weight loss from recorded serial weights over time, this information is commonly not available.

Body fat and lean muscle mass is also estimated using bioelectrical impedance or anthropometric measures like mean upper arm circumference (MUAC) or mid-arm circumference.
• MUAC measures the circumference of the left upper arm at the mid-point between the tip of the shoulder and also the tip of the elbow (olecranon process and also the acromium).
• MUAC of but 22 cm for girls and 23 cm for men are implicative chronic energy deficiency.
• Although connotative malnutrition, it’s unclear whether MUAC predicts mortality and morbidity. The MUST screening tool and therefore the MNA both use mid-arm circumference measures as a part of their assessment.

Bioelectrical impedance measures are available to be used with wheelchair bound and bedbound patients, although bioelectrical impedance is significantly influenced by hydration status.
• Evaluate appetite and dietary intake.
• Determining if there has been a change in hunger and satiety may provide more clinically revealing information than performing a proper dietary recall.
• Patients should be questioned regarding appetite, their dietary intake in regard to their usual pattern, the amount of meals they consume per day, portion size, snacks between meals, if and once they feel full during their meal, and whether the patient likes what he or she is eating.
• The SGA, MNA, and SNAQ all evaluate aspects of dietary intake during this way.
• A more formal dietary intake assessment are often obtained with a dietetic consult.
• Perform an entire history and physical examination, and order appropriate laboratory studies.
• As a baseline, we propose laboratory evaluation for evidence of metabolic or disease, to incorporate a basic chemistry profile including glucose and electrolytes, TSH, complete blood count (CBC), and CRP if cachexia is suspected.
• Chest and plain abdomen radiographs could also be considered.
• Although studies describing the causes of IVL have routinely performed chest x-rays and abdominal films, there’s no clear evidence of their value. Order addition studies supported suspicion of underlying disease from the patient’s history and examination.
Those with no localizing findings and with normal complete blood count, biochemical profile, or chest and plain abdomen radiographs are considered by some to possess isolated involuntary weight loss (IIVL).
In one series, a bit quite one-third of patients with IIVL were ultimately diagnosed with a malignancy.
statistical method found the strongest predictors of neoplasm within the setting of IIVL were age >80 years, white blood corpuscle count >12,000/mm3, albumen <3.5 g/dL, serum alkaline phosphatase > 300 UI/L, and serum lactate dehydrogenase (LDH) >500 IU/L.
These authors recommend CBC, ESR, albumin, liver function studies, LDH, and abdominal ultrasound.
Subsequent evaluation
There are not any clear guidelines for the way to proceed within the assessment of a patient with weight loss and negative initial findings.
The diagnostic yield of a thoracic/abdominal/pelvic CT examination to assess for occult or metastatic malignant disease has not been determined.
Incidental findings are common, the studies are costly, and will be inappropriate in patients who are frail or who have multiple comorbidities.
• In the absence of evidence-based recommendations, we advise ordering a thoracic/abdominal/pelvic CT scan with and without contrast for the patient with significant ongoing weight loss.
• An MRI is also ordered as an alternate when IV contrast can’t be administered, assuming there are not any contraindications; patients with chronic renal disorder shouldn’t be gadolinium.
• Upper gastrointestinal endoscopy is indicated for patients with early satiety.
• Colonoscopy isn’t indicated within the evaluation of weight loss, as carcinoma doesn’t usually induce weight loss or cachexia unless there’s obstruction or extensive metastases


When an underlying explanation for weight loss is identified, like depression, a medical illness, or inability to chew food, it’s obviously important to treat the condition.
additionally, nutritional repletion should be provided to revive the patient to a target weight, with recognition that weight correction within the older population is a smaller amount readily accomplished than in younger people.
The Council for Nutritional Clinical Strategies in Long-Term Care has developed an evidence-based approach to nutritional surveillance and management for patients in long run care .
Treatment recommendations are supported common reversible causes of malnutrition, as described by the acronym “MEALS ON WHEELS” ( table 2 ). Likewise, the American Academy of Home Care Physicians has developed guidelines for unintended weight loss in home care patients .
Data from studies of acute hospitalization in older patients suggest that up to 71 percent are at nutritional risk or are malnourished .
One randomized trial found that individualized nutritional management by a dietician (involving one visit during hospitalization and three home visits following discharge) resulted in improved scores on the Mini Nutritional Assessment and better albumin levels within the intervention group, compared to manages .
Decreased mortality rates at six months were also found (3.8 versus 11.6 percent for intervention and controls respectively), although high study dropout rates and issues with randomization allocation may have impacted this finding.
Calorie and protein requirements
Calorie needs (the estimated energy requirement, or EER) are often calculated in older adults using the subsequent equations :
• For women: 354.1 – (6.91 x age [y]) + PAC x (9.36 x weight [kg] + 726 x height [m]).
• For men: 661.8 – (9.53 x age [y]) + PAC x (15.91 x weight [kg] + 539.6 x height [m]).
The Physical Activity Coefficient (PAC) is decided as follows:
• Sedentary PAC = 1.0
• Low activity PAC = 1.12
• Active PAC = 1.27
• Very active PAC = 1.45
Protein needs don’t appear to alter significantly with age, although studies evaluating protein intake in older adults have shown wide variation in optimal protein requirements.
A meta-analysis of information from 19 studies of balance in older adults found no significant effect old on the number of protein required per kilogram of weight .
The Institute of medication has determined that the recommended dietary allowance (RDA) for protein for men and girls 51 years old and older is 0.80 g/kg body weight/day .

Inadequate food intake

If the patient’s food intake is inadequate:
• Lift dietary restrictions whenever possible. In one study, undernutrition (average weight loss >1 pound per month, albumen <3.5 g/dl) was related to dietary restrictions .
• Fifty-nine percent of the patients with weight loss and 75.2 percent of these with hypoalbuminemia were on some kind of dietary restriction.

In older, nutritionally high risk adults with diabetes, regular monitoring of blood sugar and adjustment of medication is preferable to dietary restriction or maybe a “no concentrated sweets” prescription.
• The short-term substitution of an everyday diet for a diet increased calorie consumption and failed to cause gross deterioration of glycemic control in an exceedingly study of chronic care patients with type 2 diabetes .

• Make sure that feeding or shopping assistance is accessible, if appropriate. in an exceedingly crossover controlled trial of feeding assistance in institution residents in danger of weight loss, those within the intervention group showed a big increase in daily caloric intake and either maintained or gained weight, whereas those within the control group lost weight.

• Feeding assistance was resource-intensive and required a mean 37 more minutes of staff time per meal .

• Social work support could also be important if inadequate finances are contributing to poor intake.
• Assure that meals and foods meet individual tastes. Suggest offering foods that fit the patient’s ethnic or regional preferences.
• Consider ways to supplement the patient’s diet.
• Increase the nutrient density of food. as an example, increase protein content by adding milk, whey protein (found in many food stores), egg whites, or tofu.
• Increase fat content by adding oil (or other “good fat”) in preparation of sauces, fresh or cooked vegetables, and grains or pasta.
• If weight doesn’t improve, offer daytime snacks between meals.
• Give a daily multivitamin and mineral supplement until the reason behind inadequate intake is set.
• Consider a liquid dietary supplement

Nutritional supplements
A meta-analysis evaluated 55 randomized trials of nutritional supplements containing protein and energy to stop malnutrition in older, high-risk patients.
Studies were generally judged to be of poor quality, because of lack of blinding and intent to treat analysis.
The trials evaluated supplements providing between 175 and 1000 additional kcal/day and between 10 and 36 g protein/day.
Most subjects (45 percent) were hospitalized for stroke; 16 percent were community-based and 10 percent in long-term care facilities.
Nutritional supplementation resulted in modest improvement in percentage weight change (weighted mean difference 1.75 percent, 95% CI 1.2 to 2.3), with slightly greater weight increase in patients reception or in long-term care.
Overall mortality was reduced within the groups receiving nutritional supplement, compared to control, but there was no mortality impact for patients living reception, and no improvement in functional status.
The greatest mortality impact was found in hospitalized undernourished patients who were 75 years or older, and who received supplements with higher calorie content.
Complication rates were lower for hospitalized patients who received supplementation, but there was no change in hospital length of stay.
In another meta-analysis, there was some evidence that volitional nutrient support (VNS) improved survival among malnourished geriatric patients .
Findings were significant for low-quality trials; two top quality trials found benefit for VNS during this population, but the difference from control failed to reach statistical significance.
A randomized crossover trial of organic compound supplements in 41 sarcopenic older adults demonstrated increases in whole-body lean mass at six and 12 months. This study also demonstrated that supplementation led to improved nutrition as reflected by Mini Nutritional Assessment (MNA) scores, improved albumin levels, decreased scores for depression measured by the Geriatric Depression Scale (GDS), and better hand grip strength .
More studies are needed within the sarcopenic geriatric population before aminoalkanoic acid supplementation will be generally recommended in clinical practice .
Appetite stimulants
Use of appetite stimulants (orexigenics) could also be considered, although there are few studies of use of those medications within the older population with weight loss and failure to thrive.
There is inadequate information to work out the suitable use of orexigenics in older adults with cachexia.
The complex interplay between inflammation, catabolism, and nutritional substrate in cachexia demands multimodal interventions that address all three elements.
Megestrol acetate — progestogen , a progestational agent, has been shown to yield weight gain in patients with anorexia and cachexia. progestogen has demonstrated weight gain and improved quality of life for patients with cancer .
In a randomized trial, progestin 800 mg daily for 12 weeks improved appetite and sense of well-being during a group of home residents.
However, weight gain wasn’t found to be significant (>4 lbs) until three months after treatment .
Weight gain was more prominent in residents with elevated cytokine concentrations.
Patients treated with progestin should be watched closely for edema and worsening of congestive failure.
Small studies have also demonstrated impaired function of the corticoadrenal axis ,and increased incidence of deep thrombosis in patients treated with megestrol.
Megestrol may have adverse effects on muscle. in a very randomized trial of exercise training and megestrol in older veterans, subjects who took megestrol had less gain in muscle strength or functional performance.


Dronabinol has been shown to boost appetite in patients with AIDS; it had been not as effective as megestrol in patients with advanced cancer .
Dronabinol has not been well-studied in older adults. A limited non-randomized trial showed that dronabinol could also be useful for anorexia, weight gain, and behavior problems in patients with advanced Alzheimer disease who were refusing food .

Dronabinol has significant CNS side effects, limiting its use for many older adult populations.


Mirtazapine , an antidepressant that ends up in more weight gain than SSRI antidepressants, is often used for management of depression and weight loss in older adults.
However, few studies are specifically performed to judge its impact on weight among older adults with weight loss.
Two studies in rest home residents didn’t show conclusive benefit for mirtazapine over other non-tricyclic antidepressants .


The National Heart, Lung and Blood Institute clinical guidelines define overweight as a BMI of 25 to 29.9 and obesity as a BMI of 30 or greater .
For the population as an entire, higher body weights are related to increase in all-cause mortality, moreover as morbidity associated with hypertension, dyslipidemia, type 2 diabetes, coronary cardiovascular disease, stroke, gallbladder disease, osteoarthritis, sleep disorder and respiratory problems, and endometrial, breast, prostate, and colon cancers.

Several studies suggest that the link of overweight or obesity to mortality declines over time:
• Data from the Longitudinal Study of Aging found that a comparatively high BMI (30 to 35 for ladies and 27 to 30 for men) was related to minimal excess risk for mortality in adults older than 70 years old .
• A longitudinal study of over 500,000 adults within the US found a decrease within the association of obesity with upset mortality over time .
• Data from several other long-term observational studies, including the Cardiovascular Health Study, the Medicare Current Beneficiary Surveys , and also the National future Care Survey have also found that being overweight doesn’t increase mortality risk for people age 65 years and older.
However, BMI and weight might not be reliable indicators of overweight or obesity in older populations, where normal weight may reflect loss of muscle mass instead of decreased adiposity.
A few studies suggest that being overweight as an older adult is related to increased mortality:
• In a study of men 60 to 79 years within the uk, mortality wasn’t increased for overweight or obese participants as defined by BMI .
• However, mortality risk was increased with increasing waist circumference and with BMI, when data were corrected for differences in midarm muscle circumference. These findings suggest that cardiorespiratory fitness and muscle mass may play a very important role within the relationship between BMI and mortality.
• Another report found a U shaped pattern in women ≥65 years old, comparing mortality across weight quintiles, with lower mortality for ladies within the middle 3 quintiles .
• A J-shaped pattern for BMI and mortality was demonstrated in another study of adults, predominantly men, over age 60.
• In this study, BMI within the overweight range was protective.
Though the mortality risk of obesity may lessen with age, there are still potential metabolic and functional benefits to weight loss within the obese older adults.
Increasing obesity in older adults is related to new or worsening disability and weight loss can improve physical function and quality of life for several older adults.
Recommendations to lose or not has to be individualized to the chance profile of particular patients.
Those who are experiencing significant adverse effects related to obesity (such as pain from osteoarthritis or obstructive sleep apnea) should be encouraged to pursue cautious weight loss, but only within the context of normal exercise and appropriate calcium and ergocalciferol supplementation.
Negative outcomes related to weight loss in overweight older adults include loss of muscle mass and reduce in bone mineral density; both of those could also be mitigated with regular exercise .

Vitamin B12 deficiency
The prevalence of B12 deficiency in older adults ranges between 10 and 20 percent .
Some persons with low normal serum B12 levels may of course be deficient, with resultant neurologic, psychological, or hematologic disease.
The diagnosis might have to be made by measurement of methyl malonic acid, which is elevated with B12 deficiency.

In the past, a majority of B12 deficiencies were thought to result from factor deficiency.
It is now known that approximately 15 percent of older adults (>60 years) poorly absorb protein-bound B12.
This is a results of malabsorption of the food-protein-B12 complex within the stomach, associated with gastric achlorhydria and infrequently related to atrophic gastritis .
This may be consequent to current or past H pylori infection.
Concern had been raised that folate fortification of foods may mask macrocytic anaemia in those with B deficiency. However, a study using NHANES data for older adults within the post-folate fortification years found that those with B12 deficiency and better folate levels were more likely to be anemic and to own cognitive impairment than patients with normal folate levels .

Given the high prevalence of B12 deficiency and therefore the ease and safety of treatment, some have advocated routinely screening adults over the age of 65 with a serum B complex assay .
However, this policy has not been endorsed in formal screening guidelines for the geriatric population.
Patients with B12 deficiency can generally be treated with oral B12 and will like increasing the intake of B12 in food.
Because B12 malabsorption is common in older adults, with potentially significant effects of B deficiency on the system, individuals >51 years old should take supplements containing antipernicious anemia factor, or eat fortified food products.
it’s prudent to advocate a daily intake of 10 to fifteen mcg .
For food cobalamin malabsorption-induced B12 deficiency, ongoing therapy with 1,000 mcg per day of oral crystalline cyanocobalamin may correct serum B-complex vitamin levels and yield adequate hematological responses .

Vitamin D deficiency
Lack of sun exposure, impaired skin synthesis of previtamin D, and decreased hydroxylation within the kidney with advancing age contribute to marginal cholecarciferol status in many older adults .
additionally, dietary D intake is commonly low in older subjects.
it’s been estimated that approximately one-half of older women consume but 137 international units (units)/day of fat-soluble vitamin from food, and nearly one-quarter consume but 65 units/day .

Inadequate fat-soluble vitamin status has been linked with muscle weakness, functional impairment, depression, and increased risk of falls and fractures .
An observational study during a large integrated healthcare system found an association between low D and increased prevalence of diabetes, hypertension, hyperlipidemia, and peripheral vascular disease .
Lower serum 25-hydroxyvitamin D concentrations in older persons have also been related to a greater risk of future rest home admission .
Patients with calciferol insufficiency can also have relative hypocalcemia and high serum internal secretion (PTH) concentrations; this secondary hyperparathyroidism is attenuated by the administration of fat-soluble vitamin supplements .

Many older adults will have low levels of serum of 25-hydroxyvitamin D levels (<20 ng/mL or 50 nmol/L).
Older individuals at higher risk for cholecarciferol deficiency include those that are institutionalized, homebound, have limited sun exposure, obesity, dark skin, osteoporosis, or malabsorption. Monitoring of serum levels of 25-hydroxyvitamin D (25-OHD) is suggested for those at high risk, with the goal of achieving levels ≥30 ng/mL. Testing at three to four months following initiation of D supplements, if needed, should be done to assure that the target has been achieved.

Increased consumption of dietary sources of viosterol should be encouraged all told older adults.
In 2010, the Institute of drugs (IOM) released a report on dietary intake requirements for calcium and calciferol for normal healthy persons .
The Recommended Dietary Allowance (RDA) of fat-soluble vitamin for adults through age 70 years is 600 IU with the RDA increasing to 800 IU after age 71.

Vitamin D supplementation with cholecalciferol (vitamin D3) in doses of 600 to 800 mg daily is recommended for people with serum 25OHD level within the range of 20 to 30 ng/mL. Some individuals may have higher doses.
Regimens for ergocalciferol supplementation for those with serum 25OHD levels <20 ng/mL are discussed separately

Inadequate intake of calcium
Calcium nutrition is strongly influenced by age. The efficiency of calcium absorption from the canal decreases significantly after age 60 in both sexes.
Individuals between 70 and 90 years old absorb about one third less calcium than do younger adults.
Osteoporosis affects quite 10 million people within the u. s., and causes over 1.5 million fractures within that population every year .

Given the impact of calcium deficiency on cortical bone loss, the adequate intake (AI) reference value for Ca for those >51 years old was increased from 800 (1989 RDA) to 1200 mg/d.
Food sources of calcium and available calcium supplements are shown in tables ( table 3 and table 4 ).
Multivitamin supplementation
Whether multivitamin (MVI) supplementation should be routinely recommended to older adults remains a source of some controversy and confusion.
Many older adults use MVI supplements.
within the 1999-2000 National Health and Nutrition Examination Survey (NHANES), 35 percent of adults within the us used multivitamin-multimineral supplements (MVM) and older adults were more likely than younger groups to use them (OR 1.7, 95% CI 1.3-2.2).
In a longitudinal cohort study of predominantly white older women, the employment of dietary supplements increased significantly between 1986 and 2004 (from 63 to 85 percent of girls reporting use of a minimum of one supplement daily) .

MVM supplementation has been recommended for older adults who are more likely to own compromised nutritional status (such as those within the long run care setting), to assist achieve recommended intakes of certain micronutrients .
evidence, however, provides only weak support for this practice:
• In a study of 263 older adults attending senior centers, nutrient intake was estimated from dietary recalls and reported use of MVM supplementation .
• Subjects who reported taking MVM were calculated to own improved intakes of vitamins E, D, B6, folic acid , and calcium, but were likely to exceed the Tolerable Upper Limit for niacin, folic acid, and antiophthalmic factor.
• In a study of 4384 adults 51 years old and older, supplements improved the nutrient intake of older adults. After accounting for the contribution of supplements, 80 percent or more of users met the estimated average requirement (EAR) for vitamins A, B6, B12, C, and E yet as for folate, iron, and zinc, but not for magnesium.
• However, some supplement users, particularly men, exceeded Tolerable Upper Intake Levels for iron and zinc and atiny low percentage of ladies exceeded the Tolerable Upper Intake Level for antiophthalmic factor .
• A few studies have suggested that MVM might reduce the incidence of infections, and upper tract infections particularly.
• during a systematic review of eight randomized trials of multivitamins and mineral supplements primarily involving older adults, three studies found that MVM reduced the amount of days spent with infection by 17.5 (95% CI 11-24) but analysis of 4 studies showed no impact on the infection rate .
• In an 18-month randomized trial involving 763 institutionalized older adults from 21 long-term care facilities, there was no statistically significant difference within the rate of infections within the supplement and placebo groups .
• In a cohort study of 38,772 older women followed for over 20 years with a mean age of 61.6 at baseline, supplementation with daily multivitamins was related to alittle increase in total mortality (HR 1.06, 95% CI 1.02-1.10) .

Therefore, routine supplementation with multivitamins and minerals isn’t indicated to scale back infections in frail seniors and is probably going not beneficial unless it’s clear that the older adult isn’t meeting his or her micronutrient needs because of low overall intake. The 2006 NIH Consensus Conference on the employment of MVM found evidence insufficient to recommend for or against the employment of MVMs to stop chronic disease for the US population generally .

UpToDate offers two kinds of patient education materials, “The Basics” and “Beyond the fundamentals.” the fundamentals patient education pieces are written in plain language, at the 5 th to six th grade reading level, and that they answer the four or five key questions a patient might need a couple of given condition.
These articles are best for patients who need a general overview and preferring short, easy-to-read materials. Beyond the fundamentals patient education pieces are longer, more sophisticated, and more detailed.
These articles are written at the ten th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to the current topic.
We encourage you to print or e-mail these topics to your patients. (You also can locate patient education articles on a range of subjects by searching on “patient info” and therefore the keyword(s) of interest.)
• Basics topics

SUMMARY and suggestions

• The involuntary loss of quite 5 to 10 percent of an older person’s usual weight during one year is a vital clinical sign related to increased risk for mortality.
• Weight loss should thus be met concernedly and prompt a groundwork for the cause.
• Involuntary weight loss is mostly associated with one or a mix of 4 conditions: inadequate dietary intake, appetite loss (anorexia), muscle atrophy (sarcopenia), or inflammatory effects of disease (cachexia).
• Inadequate dietary intake may relate to social, psychological, medical, and physiologic issues. Depression is that the most prevalent associated condition in several studies, with cancer because the second most typical cause.
• Pro-inflammatory cytokines are common in older adults and are particularly elevated in patients with cachexia.
• Sarcopenia is commonly associated with a discount in testosterone and estrogen and increase in insulin resistance
• Evaluation of weight loss should include serial weight measurements, dietary or appetite assessment, history, physical examination, and screening laboratory studies (CBC, chemistry profile, thyroid studies). Additional studies should be supported findings of the initial evaluation and will include upper GI endoscopy for patients with early satiety or thoracic/abdominal/pelvic CT scan for patients with unexplained ongoing weight loss.
• Treatment should be directed at the underlying cause (ie, treatment for depression) still as dietary modification.
• Nutritional restrictions should be lifted; patients with diabetes may had best with an everyday diet and adequate monitoring.
• High-calorie foods should be provided.

We suggest providing oral nutritional supplementation for patients who don’t regain weight with adjustments in meal preparation and diet ( Grade 2B ). we advise not treating patients with appetite stimulants ( progestogen or dronabinol ) because of marginal benefit and potential side effects ( Grade 2B
• Mortality risk in people over age 70 isn’t significantly impacted by an elevated BMI within the 25.0 to 29.9 range.
• Advice regarding weight loss for the overweight older person should be tailored to the individual, assessing the impact of excess weight on their quality of life, and will include the requirement for normal exercise.
• Vitamin B12 deficiency affects about 15 percent of individuals >60 years within the US and most typically relates to malabsorption of food-protein-B12 complexes.
• Oral B12 supplements, 1000 mcg daily, can usually correct B12 deficiency within the older adult. Daily intake of B12 10 to fifteen mcg, by supplement or fortified products within the diet, is suggested for people >50 years.

• Vitamin D deficiency is additionally common within the older population. viosterol supplements or fortified foods should supply 600 to 800 IU of D per day for older adults. Additionally, 1200 mg/d of elemental calcium should be provided daily.

Nutrition for Tennis-Practical Recommendations

Tennis may be a pan-global sport that’s played year-round in both hemispheres.

This places notable demands on the physical and psychological preparation of players and included in these demands are nutritional and fluid requirements both of coaching and match- play.

Thus, the aim of this text is to review nutritional recommendations for tennis.

Notably, tennis players don’t excel in any particular physiological or anthropometric characteristic but are well adapted all told areas which is perhaps a results of the numerous nature of the training demands of match play.

Energy expenditures of 30.9 ± 5.5 and 45.3 ± 7.3 kJ·min-1 are reported in women and men players respectively irrespective of court surface.

Tennis players should follow a habitually high carbohydrate diet of between 6-10 g·kg-1·d-1 to make sure adequate glycogen stores, with women generally requiring slightly but men. Protein intake guidelines for tennis players training at a high intensity and duration on a day after day should be ~1.6 g·kg-1·d-1 and dietary fat intake mustn’t exceed 2 g·kg-1·d-1. Caffeine in doses of three mg·kg-1 provides ergogenic benefit when taken before and/or during match play.

looking on environmental conditions, sweat rates of 0.5 to and over 5 L·hr-1 and sodium losses of 0.5 – 1.8 g are recorded in men and ladies players.

200 mL of fluid containing electrolytes should be consumed every change-over in mild to moderate temperatures of < 27°C but in temperatures greater than 27°C players should aim for ≤ 400 mL. 30-60 g·hr-1 of carbohydrate should be ingested when golf exceeds 2 hours. Key Points Tennis players should follow a habitually high carbohydrate diet of between 6-10 g·kg-1 to confirm adequate glycogen stores, with women generally requiring slightly but men.

Protein intake guidelines for tennis players training at a high intensity and duration on a day after day should be ~1.6 g·kg-1·d-1. Dietary fat intake shouldn’t exceed 2 g·kg-1·d-1. Caffeine in doses of three mg·kg-1 can provide ergogenic benefit when taken before and/or during match play. 200 mL of fluid containing electrolytes should be consumed every change-over in mild to moderate temperatures of < 27°C but in temperatures greater than 27°C players should aim for ≥ 400 mL. 30-60 g·hr-1 of carbohydrate should be ingested when golf game exceeds 2 hours.

During periods of travel, specific dietary requirements is communicated with agencies and hotels before arrival and within the event that suitably nutritious foods don’t seem to be available within the host country, players can bring or send non-perishable foods and goods where customs and quarantine laws allow.


Treatment of hypocalcemia  


— Hypocalcemia is also related to a spectrum of clinical manifestations, starting from few if any symptoms if the hypocalcemia is mild and/or chronic, to severe life-threatening symptoms if it’s severe and/or acute. Thus, the management of hypocalcemia depends upon the severity of symptoms. In patients with acute symptomatic hypocalcemia, intravenous calcium gluconate is that the preferred therapy, whereas chronic hypocalcemia is treated with oral calcium and viosterol supplements. The treatment of hypocalcemia are reviewed here. The etiology, clinical manifestations, and diagnostic approach to hypocalcemia are reviewed separately.


— Calcium in serum is absolute to proteins, principally albumin. As a result, total serum calcium concentrations in patients with low or high albumen levels might not accurately reflect the physiologically important ionized (or free) calcium concentration. As an example, in patients with hypoalbuminemia, total serum calcium concentration is also low when serum ionized calcium is normal. The serum total calcium concentration falls approximately 0.8 mg/dL for each 1 g/dL reduction within the albumin concentration. Thus, in patients with hypoalbuminemia or hyperalbuminemia, the measured serum calcium concentration should be corrected for the abnormality in albumin or for traditional units If there’s uncertainty whether the corrected serum calcium is reflective of the ionized calcium, and if a laboratory known to live ionized calcium reliably is obtainable, some authorities opt to measure the ionized calcium directly. Direct measurement of the ionized calcium concentration might be considered in patients with symptoms of hypocalcemia within the setting of a traditional total calcium concentration. Symptomatic hypocalcemia with normal total calcium but low ionized calcium can occasionally occur in patients with acute alkalosis thanks to increased binding of calcium to albumin. In patients with asymptomatic hypocalcemia, it’s important to verify with repeat measurement (ionized calcium or total serum calcium corrected for albumin) that there’s a real decrease within the calcium concentration.


— The treatment of hypocalcemia varies with its severity and therefore the underlying cause. The severity of symptoms (paresthesias, carpopedal spasm, tetany, seizures) and signs (Chvostek’s or Trousseau’s signs, bradycardia, impaired cardiac contractility, and prolongation of the QT interval) depends upon absolutely the level of calcium, furthermore because the rate of decrease. Patients with acute hypocalcemia are symptomatic at serum calcium values that might not cause symptoms in patients with chronic hypocalcemia (eg, hypoparathyroidism). Clinical manifestations also vary with other factors like the arterial pH and therefore the reason for hypocalcemia. There are few studies examining the optimal treatment of hypocalcemia. Most recommendations are based upon accepted practice or clinical experience We recommend intravenous calcium for symptomatic patients (carpopedal spasm, tetany, seizures), for patients with a chronic QT interval, and for asymptomatic patients with an acute decrease in serum corrected calcium to ≤7.5 mg/dL (1.9 mmol/L). For those with milder symptoms of neuromuscular irritability (paresthesias) and corrected calcium concentrations greater than 7.5 mg/dL, oral calcium supplementation may be initiated. If symptoms don’t improve with oral supplementation, we recommend switching to intravenous calcium. When vitamin D deficiency or hypoparathyroidism is that the reason for hypocalcemia, administration of calcium alone is typically only transiently effective. Long-term management requires the addition of cholecarciferol. Recombinant human internal secretion is approved for the treatment of osteoporosis but isn’t yet standard look after hypoparathyroidism due to high cost and also the necessity for subcutaneous administration. Intravenous calcium — Intravenous calcium is indicated for acutely symptomatic patients, as can occur when there’s a rapid and progressive reduction in serum calcium (eg, acute hypoparathyroidism following post-radical neck dissection for head and neck cancer). it’s also indicated for asymptomatic hypocalcemia in several other settings. These include patients with acute decreases in serum calcium to ≤7.5 mg/dL (1.9 mmol/L) who may develop serious complications if untreated, and patients with milder degrees of hypocalcemia or with chronic hypocalcemia (due to hypoparathyroidism) who become unable to require or absorb oral supplements, as may occur after complex surgical procedures requiring prolonged recuperation. Intravenous calcium isn’t warranted as initial therapy for asymptomatic hypocalcemia in patients with impaired renal function in whom correction of hyperphosphatemia and of low circulating 1,25-dihyroxyvitamin D are usually the first goals Initially, intravenous calcium (1 to 2 g of calcium gluconate , adore 90 to 180 mg elemental calcium, in 50 mL of 5 percent dextrose) is infused over 10 to twenty minutes. The calcium mustn’t tend earlier, due to the chance of great cardiac dysfunction, including systolic arrest This dose of calcium gluconate will raise the serum calcium concentration for less than two or three hours; as a result, it should be followed by a slow infusion of calcium in patients with persistent hypocalcemia. Either 10 percent calcium gluconate (90 mg of elemental calcium per 10 mL) or 10 percent salt (270 mg of elemental calcium per 10 mL) is wont to prepare the infusion solution. Calcium gluconate is sometimes preferred because it’s less likely to cause tissue necrosis if extravasated. An intravenous solution containing 1 mg/mL of elemental calcium is ready by adding 11 g of calcium gluconate (equivalent to 990 mg elemental calcium) to normal saline or 5 percent dextrose water to produce a final volume of 1000 mL. This solution is run at an initial infusion rate of fifty mL/hour (equivalent to 50 mg/hour).

The dose are often adjusted to take care of the serum calcium concentration at the lower end of the traditional range (with the serum calcium corrected for any abnormalities in albumin as noted above). Patients typically require 0.5 to 1.5 mg/kg of elemental calcium per hour. The infusion should be prepared with the subsequent considerations

: • The calcium should be diluted in dextrose and water or saline because concentrated calcium solutions are irritating to veins.

  • The intravenous solution shouldn’t contain bicarbonate or phosphate, which might form insoluble calcium salts. If these anions are needed, another intravenous line (in another limb) should be used. Intravenous calcium should be continued until the patient is receiving a good regimen of oral calcium and vitamin D. Calcitriol, in a very dose of 0.25 to 0.5 mcg twice daily, is that the preferred preparation of ergocalciferol for patients with severe acute hypocalcemia thanks to its rapid onset of action (hours Concurrent hypomagnesemia  — Hypomagnesemia could be a common explanation for hypocalcemia, both by inducing resistance to hormone (PTH) and by diminishing its secretion. In patients with hypomagnesemia, hypocalcemia is difficult to correct without first normalizing the serum magnesium concentration. Thus, if the serum magnesium concentration is low, 2 g (16 meq) of sulphate should be infused as a ten percent solution over 10 to twenty minutes, followed by 1 gram (8 meq) in 100 mL of fluid per hour. Magnesium repletion should be continued as long because the serum magnesium concentration is a smaller amount than 0.8 meq/L (1 mg/dL or 0.4 mmol/L). More careful monitoring is required in patients who have impaired renal function who would be at greater risk of developing hypermagnesemia. Persistent hypomagnesemia, as occurs in some patients with ongoing gastrointestinal (eg, malabsorption) or renal losses, requires supplementation with oral magnesium, typically 300 to 400 mg daily divided into three doses. Oral calcium — Oral calcium supplementation is preferred for patients with milder degrees of acute hypocalcemia (serum corrected calcium concentration of seven.5 to 8.0 mg/dL [1.9 to 2.0 mmol/L] or a serum ionized calcium concentration above 3.0 to 3.2 mg/dL [0.8 mmol/L]) or for chronic hypocalcemia. Such patients are typically asymptomatic or at the most mildly symptomatic (eg, oral paresthesias). they will be treated initially with 1500 to 2000 mg of elemental calcium given as carbonate or calcium citrate daily, in divided doses. As an example, carbonate is 40 percent elemental calcium, so 1250 mg of carbonate contains 500 mg of elemental calcium. The dose of elemental calcium is listed on most supplement labels. The role of oral calcium as a phosphate binder in patients with chronic nephrosis is presented elsewhere. additionally to calcium, patients with ergocalciferol deficiency or hypoparathyroidism require D supplementation, which frequently permits a lower dose of calcium supplementation. viosterol and metabolites  — Several preparations of ergocalciferol are available for the treatment of hypocalcemia thanks to hypoparathyroidism or viosterol deficiency. The role of calciferol therapy in patients with chronic renal disorder is discussed separately. viosterol requirements vary considerably from patient to patient and therefore the correct dose in any given patient is primarily determined by trial and error. Because PTH is required for the renal conversion of calcidiol (25-hydroxyvitamin D) to the active metabolite calcitriol (1,25-dihydroxyvitamin D), patients with hypoparathyroidism are preferably treated with calcitriol. The initial dose of calcitriol is often 0.25 to 0.5 mcg twice daily. the varied preparations differ in onset of action, duration of action, and cost. the most important side effects are hypercalcemia and hypercalciuria, which, if chronic, can cause nephrolithiasis, nephrocalcinosis, and nephropathy Hypercalciuria is that the earliest sign of toxicity and may develop within the absence of hypercalcemia; it’s presumably to occur in patients with hypoparathyroidism since internal secretion stimulates renal calcium reabsorption. However, in patients with ergocalciferol deficiency, enhanced intestinal absorption of calcium with fat-soluble vitamin therapy and also the resulting increases in serum calcium may additionally reduce PTH concentrations, potentially leading to hypercalciuria before hypercalcemia occurs. Thus, both serum and urinary calcium should be measured frequently (two-week intervals) initially so every six months to 1 year once a stable dose is achieved. Hypercalciuria and, if present, hypercalcemia usually resolve in a very few days after cessation of therapy in patients treated with calcitriol. In contrast, recovery is slower (as long as two to a few weeks thanks to storage in fat) in patients treated with viosterol, but are often accelerated by a brief course of glucocorticoid therapy. Vitamin D — ergocalciferol deficiency is often treated with ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3). ergocalciferol is obtainable in several doses for oral administration. In some countries (not within the United States), it’s is also available for parenteral administration the foremost advantage of fat-soluble vitamin is its low cost, which is approximately 20 percent that of the ergocalciferol metabolites. Disadvantages include the need for hepatic and renal metabolism and slow onset and long duration of action. It must lean daily for several weeks before the complete effect becomes evident and hypercalcemia, should it occur, can persist for 2 to a few weeks after it’s discontinued. Calcitriol — Calcitriol (1,25-dihydroxyvitamin D, Rocaltrol) is most useful in diseases within which its renal synthesis is impaired, like nephropathy or hypoparathyroidism. it’s the foremost active metabolite of fat-soluble vitamin. the benefits of calcitriol include lack unavoidably for endogenous activation, rapid onset of action (hours), and a biologic half-life of about four to 6 hours. While hypercalcemia is more common during treatment with calcitriol than with viosterol, cessation of treatment is followed by resolution of hypercalcemia in a very few days instead of some weeks Other vitamin D analogues   — fat-soluble vitamin metabolites may be wont to treat hypocalcemia, particularly when there’s abnormal viosterol metabolism (renal or liver disease). The recommended preparation and dose vary with the clinical condition.
  • • Alfacalcidol (1-alpha-hydroxyvitamin D3) could be a synthetic analog of calciferol that’s converted within the liver to the active metabolite 1,25-dihydroxyvitamin D. just like calcitriol, it’s a rapid onset of action and comparatively short half-life. Although it’s not available within the us, it’s utilized in other countries for the treatment of hypocalcemia related to hypoparathyroidism and as a treatment adjunct in chronic renal disorder.
  • • Dihydrotachysterol is that the functional equivalent of 1-hydroxyvitamin D, in this only 25-hydroxylation within the liver is required to make the active drug. As a result, dihydrotachysterol is effective in patients in whom renal 1-hydroxylation is impaired, like those with chronic nephropathy. it’s a rapid onset of action and a comparatively short duration of action, so toxicity resolves in a very few days.
  • • Calcidiol (25-hydroxyvitamin D) doesn’t require hepatic 25-hydroxylation, and is therefore most useful in patients with disease. Its action is more rapid and not as prolonged as that of cholecarciferol, but slower in onset and more prolonged than that of calcitriol.


— Hypoparathyroidism occurs when there’s abnormal endocrine gland development, destruction of the parathyroid glands (autoimmune, surgical), altered regulation of hormone (PTH) production, or impaired PTH action. Most patients with hypoparathyroidism require lifelong calcium and vitamin D supplementation. An exception is that the occurrence of transient hypoparathyroidism after thyroidectomy or parathyroidectomy. The goals of therapy in patients with hypoparathyroidism are to alleviate symptoms and to lift and maintain the serum calcium concentration within the low-normal range, eg, 8.0 to 8.5 mg/dL (2.0 to 2.1 mmol/L). Attainment of upper values isn’t necessary and is sometimes limited by the event of hypercalciuria because of the loss of renal calcium retaining effects of PTH. The initial dose of oral calcium should be 1.0 to 1.5 g of elemental calcium daily, in divided doses Although carbonate is commonly used (it is that the least expensive), it should be less well-absorbed in older patients and people who have achlorhydria. These patients could be treated with another preparation, like calcium citrate . Although a range of viosterol preparations will be wont to treat hypoparathyroidism calcitriol is commonly thought to be the treatment of choice A typical starting dose is 0.25 mcg twice daily, with weekly dose increments to realize a low-normal serum calcium. Many patients require up to 2 mcg daily. Monitoring of urinary and serum calcium and serum phosphate are required weekly initially, until a stable serum calcium concentration (at the low end of the conventional range) is reached. Thereafter, monitoring at three- to six-month intervals is sufficient Preventing hypercalciuria  — a rise in urinary calcium excretion could be a predictable consequence of raising the serum calcium in patients with hypoparathyroidism These patients lack the conventional stimulatory effect of PTH on renal tubular calcium reabsorption and so excrete more calcium than normal subjects at the identical serum calcium concentration. Thus, completely correcting hypocalcemia may cause hypercalciuria, which may produce nephrolithiasis, nephrocalcinosis, and possible chronic nephropathy To prevent these complications, urinary calcium excretion should be measured periodically and therefore the dose of calcium and calciferol reduced if it’s elevated (≥300 mg in 24 hours). Some patients with hypoparathyroidism require a thiazide diuretic (25 to 100 mg daily), with or without dietary sodium restriction, to decrease urinary calcium excretion A thiazide is usually added when the 24-hour urinary calcium approaches 250 mg In patients who develop thiazide-induced hypokalemia, potassium supplementation is important. The mechanism by which both PTH and thiazides enhance distal calcium reabsorption is reviewed elsewhere. Recombinant human PTH  — The administration of recombinant internal secretion (PTH), which is obtainable for the treatment of osteoporosis, holds promise as a treatment for hypoparathyroidism. Subcutaneous administration of PTH 1-34 and PTH 1-84 are investigated, as illustrated by the following:

  • In two randomized trials from the identical group, subcutaneous administration of synthetic PTH 1-34 controlled hypocalcemia with a lower risk of hypercalciuria in comparison with calcitriol (all subjects received oral calcium supplementation) Twice-daily administration of PTH 1-34 provided better metabolic control and allowed a discount in total daily PTH dose (46 versus 97 mcg daily) Similar findings were noted during a trial comparing once- versus twice-daily PTH administration in 14 children with chronic hypoparathyroidism (total daily dose 25 versus 58 mcg

In an open label study of PTH 1-84 (100 mcg every other day) in 30 hypoparathyroid patients, PTH 1-84 significantly reduced supplemental calcium and calcitriol requirements without altering serum and urinary calcium concentrations Bone mineral density significantly increased within the lumbar spine (2.9 percent) and decreased within the distal one-third radius (2.4 percent). Recombinant human PTH may additionally improve abnormal skeletal properties in hypoparathyroidism. in a very histomorphometric analysis of paired iliac crest biopsy samples from 30 patients with primary hypoparathyroidism, PTH treatment of hypoparathyroidism was related to a rise within the remodeling rate in both trabecular and cortical compartments with tunneling resorption within the trabecular compartments These findings suggest that PTH restores bone metabolism to levels more typical of euparathyroid individuals. Recombinant human PTH isn’t yet approved to be used in hypoparathyroidism, primarily since the long-term safety of this dose (relative to its skeletal effects) has not been established, particularly in growing children who is also at greater risk of osteosarcoma. additionally, recombinant PTH is way costlier than standard therapy with calcitriol and calcium. Thyroidectomy or parathyroidectomy — Hypocalcemia could be a common problem after total or near-total thyroidectomy and partial or total parathyroidectomy in patients with primary hyperparathyroidism. As an example, hypoparathyroidism is that the most frequent complication of near-total thyroidectomy. Transient hypoparathyroidism occurs in up to twenty percent of patients after surgery for thyroid cancer and permanent hypoparathyroidism occurs in 0.8 to 3.0 percent of patients after total thyroidectomy, particularly when the goiter is extensive and anatomic landmarks are displaced and obscured. The management of post-thyroidectomy hypoparathyroidism is reviewed elsewhere. vitamin D deficient patients undergoing parathyroidectomy are at increased risk for developing postoperative hypocalcemia and hungry bone syndrome [ 21 ]. Hungry bone syndrome most frequently occurs in hyperparathyroid patients who developed bone disease preoperatively because of a chronic increase in bone resorption induced by high levels of PTH (osteitis fibrosa). In these patients, calcium is avidly obsessed by the demineralized bone after surgery, and calcium supplementation is required to take care of a standard serum calcium concentration. vitamin D deficient postparathyroidectomy patients may require prolonged, massive calcium and D therapy thanks to hungry bone syndrome. Hypoparathyroidism during pregnancy   — Special care should be taken within the management of girls with hypoparathyroidism during pregnancy and following delivery. There are conflicting data on whether calcitriol requirements fall or don’t fall during pregnancy On the opposite hand, there’s uniform agreement that calcitriol requirements decrease during lactation Serum concentrations of 1,25-dihyroxyvitamin D (calcitriol) double during a traditional pregnancy. However, intact PTH concentrations remain low-to-normal, suggesting that PTH doesn’t mediate the late partum rise in 1,25-dihydroxyvitamin D (1,25D) production. the rise in serum 1,25D is also regulated by other pregnancy hormones, which are normal in hypoparathyroid women, like PTH-related protein (PTHrP), prolactin, estrogen, and placental hormone Thus, serum calcium concentrations should be measured frequently during late pregnancy and lactation in women with hypoparathyroidism who may have an increase in serum calcium, requiring a decrease in calcitriol dose If the calcitriol dose isn’t reduced, the mix of elevated serum 1,25D and PTHrP can result in increases in intestinal absorption and bone resorption and hypercalcemia [ 28 ]. the necessity for calcitriol will return to antepartum levels with cessation of lactation.

Autosomal dominant hypocalcemia

— Autosomal dominant hypocalcemia could be a rare disorder caused by an activating mutation within the calcium-sensing receptor (CaSR). Increased activity of this receptor within the renal tubules ends up in normal or high urinary calcium excretion despite hypocalcemia; raising the patient’s serum calcium concentrations with cholecarciferol may result in additional hypercalciuria, nephrocalcinosis, and renal disorder. Fortunately, most patients with this disorder have few if any symptoms of hypocalcemia and frequently require little or no therapy. When approved, recombinant human parathormone , which reinforces calcium absorption within the tubules, could also be an alternate if therapy is required. It can raise the serum calcium concentration during this disorder with a coffee risk of exacerbating hypercalciuria. Alternatively, calcilytics, a category of medication in development that inhibit the CaSR, may provide a useful therapeutic approach within the future.

cholecarciferol deficiency

— Nutritional cholecarciferol deficiency is often treated with 50,000 international units of vitamin D2 or D3 weekly for 6 to eight weeks. Chronic renal disorder   — Few patients with chronic nephropathy have symptomatic hypocalcemia. Such patients are often treated with oral calcium to bind intestinal phosphate and to stop bone disease instead of hypocalcemia in and of itself. The addition of a vigorous sort of viosterol is required in a number of these patients. These issues are discussed very well elsewhere Hypercatabolic state — Unless they’re symptomatic from hypocalcemia (eg, tetany or cardiac arrhythmia), patients with acute hypocalcemia and hyperphosphatemia thanks to a hypercatabolic state like the tumor lysis syndrome or massive trauma mustn’t be treated with calcium until the hyperphosphatemia is corrected to stop calcium-phosphate precipitation. Hemodialysis is commonly indicated in such patients who have symptomatic hypocalcemia.

  • Pseudohypoparathyroidism  — Pseudohypoparathyroidism (PHP) refers to a bunch of heterogeneous disorders defined by targeted organ (kidney and, perhaps, bone) unresponsiveness to PTH . it’s characterized by hypocalcemia, hyperphosphatemia, and in contrast to hypoparathyroidism, elevated instead of reduced PTH concentrations. The clinical manifestations and diagnosis of this disorder are reviewed elsewhere The long-term treatment of hypocalcemia in adults with pseudohypoparathyroidism is analogous to the treatment of hypocalcemia caused by other kinds of hypoparathyroidism. However, patients with pseudohypoparathyroidism infrequently develop hypercalciuria with calcium and fat-soluble vitamin therapy Therefore, the goal of treatment with calcium and ergocalciferol is to keep up normocalcemia (rather than low-normal serum calcium as for other types of hypoparathyroidism). A typical starting dose of calcitriol is 0.25 mcg twice daily. The dose should be increased weekly to realize a standard serum calcium. Many patients require up to 2 mcg daily Approximately 1 to 2 gm of elemental calcium daily (in divided doses) is usually recommended. Patients with pseudohypoparathyroidism can also require screening for other endocrinopathies, particularly hypothyroidism and hypogonadism.


— UpToDate offers two varieties of patient education materials, “The Basics” and “Beyond the fundamentals.” the fundamentals patient education pieces are written in plain language, at the 5 th to six th grade reading level, and that they answer the four or five key questions a patient may need a few given condition. These articles are best for patients who desire a general overview and preferring short, easy-to-read materials. Beyond the fundamentals patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the ten th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to the current topic. We encourage you to print or e-mail these topics to your patients. (You also can locate patient education articles on a range of subjects by searching on “patient info” and also the keyword(s) of interest.) SUMMARY and proposals Calcium   — The treatment of hypocalcemia varies with its severity and also the underlying cause.

  • Patients with hypocalcemia who are severely symptomatic (carpopedal spasm, tetany, seizures, decreased cardiac function, or prolonged QT interval) require rapid correction of calcium levels with IV calcium therapy. We also suggest IV calcium therapy in asymptomatic patients with an acute decrease in serum corrected calcium to ≤7.5 mg/dL (1.9 mmol/L) Intravenous calcium isn’t warranted as initial therapy for asymptomatic hypocalcemia in patients with impaired renal function in whom correction of hyperphosphatemia and of low circulating 1,25-dihyroxyvitamin D are usually the first goals.
  • For those with milder symptoms of neuromuscular irritability (paresthesias) and corrected serum calcium concentrations greater than 7.5 mg/dL (1.9 mmol/L), initial treatment with oral calcium supplementation is sufficient. If symptoms don’t improve with oral supplementation, intravenous calcium infusion is required.
  • To effectively treat hypocalcemia in patients with concurrent magnesium deficiency, hypomagnesemia should be corrected first. Vitamin D

— When hypoparathyroidism (transient or permanent) or fat-soluble vitamin deficiency are the explanation for hypocalcemia, administration of intravenous calcium is merely transiently effective (as long because the infusion continues), and oral calcium might not be absorbed. In these cases, successful management requires the addition of D, which frequently permits a lower dose of calcium supplementation.

  • For the initial management of patients with hypoparathyroidism, we recommend cholecarciferol supplementation additionally to calcium ). Calcitriol is that the viosterol metabolite of choice because it doesn’t require renal activation, it’s a rapid onset of action (hours), and a shorter half-life. Other acceptable options include alfacalcidol, calciferol (ergocalciferol or cholecalciferol), or dihydrotachysterol
  • In individuals with hypocalcemia thanks to cholecarciferol deficiency, we recommend cholecarciferol repletion Nutritional deficiency (25OHD <20 ng/mL [50 nmol/L]) requires initial treatment with 50,000 units of vitamin D2 or D3 orally once per week for 6 to eight weeks, then 800 to 1000 international units of vitamin D3 daily thereafter. Permanent hypoparathyroidism
  • In patients with permanent hypoparathyroidism, the goals of therapy are to alleviate symptoms, to lift and maintain the serum calcium concentration within the low-normal range (eg, 8.0 to 8.5 mg/dL [2.0 to 2.1 mmol/L]), and to avoid hypercalciuria (maintain 24-hour urinary calcium below 300 mg
  • All patients with permanent hypoparathyroidism require adequate calcium intake (1.0 to 1.5 g elemental calcium daily).
  • Along with calcium supplementation, we recommend calcitriol instead of recombinant human parathormone (PTH) The long-term safety of PTH has not been established. additionally, recombinant PTH is far dearer than standard therapy with calcitriol. However, in patients with refractory hypercalciuria, PTH could be a reasonable option.
  • The initial treatment of hypercalciuria in patients with hypoparathyroidism is reducing the dose of calcium and fat-soluble vitamin. Some patients would require the addition of thiazide diuretics.

Calcium and D supplementation in osteoporosis

Osteoporosis may be a disorder of bone characterized by reduced mineral density and bone mass. Multiple therapeutic regimens are designed to forestall or treat bone loss in postmenopausal women and also the elderly. the primary step within the prevention or treatment of osteoporosis is ensuring adequate nutrition, particularly maintaining an adequate intake of calcium and cholecarciferol. Adequate calcium and ergocalciferol nutrition is vital in people of all ages, especially in children and therefore the elderly within the latter group, as an example, the administration of calcium and viosterol reduces the speed of bone loss and will decrease fracture risk during this same population, calcium and D supplementation also reduces tooth loss Calcium and calciferol supplementation within the treatment of osteoporosis are reviewed here. Detailed information regarding pharmacologic therapy for osteoporosis and also the role of calcium within the pathogenesis of osteoporosis is discussed separately.


— Calcium and vitamin D are necessary for normal skeletal homeostasis. D enhances intestinal absorption of calcium. Low concentrations of D are related to impaired calcium absorption, a negative calcium balance, and a compensatory rise in internal secretion, which ends in excessive bone resorption.

Careful calcium balance studies have shown that calcium balance is said to calcium intake; the less calcium one takes in, the more negative the calcium balance. this will be reversed by increasing calcium intake and maintaining adequate fat-soluble vitamin stores. In general, calcium balance becomes positive at a mean calcium intake of 1000 mg/day in premenopausal women and 1500 mg/day in postmenopausal women who don’t take estrogen The importance of adequate calcium and viosterol intake for skeletal health is supported by several observational studies and by randomized trial data. Observational data — Many studies have shown an inverse relationship between serum concentrations of 25-hydroxyvitamin D (25OHD) and hormone (PTH) The maximal suppression of PTH by vitamin D is one criterion by which the optimal serum 25OHD concentration is defined. Estimates vary widely but range from 20 to 40 ng/mL (50 to 100 nmol/L) Other experts support the thesis that suppression of PTH by 25OHD follows a continuum across a large range of viosterol concentrations, and levels above 20 ng/mL are capable suppress PTH, assuming normal renal function The compensatory rise in hormone, which occurs within the setting of low calciferol, leads to excessive bone resorption. Many studies, including an outsized population-based study (NHANES-III) that included 13,432 participants, have shown a positive association between serum 25OHD and bone mineral density additionally, in an exceedingly prospective cohort study of 1279 community-dwelling older men, those with 25OHD <20 ng/mL (50 nmol/L) had significantly higher rates of hip bone loss over time (approximately 0.5 compared with 0.3 percent/year in men with serum 25OHD >20 ng/mL In several but not all observational studies, lower serum concentrations of 25-hydroxyvitamin D (25OHD, calcidiol) were related to the next risk of hip fracture. In one in every of the most important of those studies, 400 women with hip fracture were compared with 400 matched controls and followed for seven years The mean serum 25OHD concentrations measured at study entry were significantly lower in patients who subsequently had a hip fracture (22 versus 24 ng/mL [56 versus 60 nmol/L]) The increased risk of hip fracture was most apparent in women with very cheap serum 25OHD concentrations (OR 1.7, 95% CI 1.0-2.8 for girls in quartile one [<19 ng/mL (47.5 nmol/L)]) compared with women in quartile four (>28 ng/mL [70.7 nmol/L]). Similar findings were reported in men (hazard ratio 2.36, 95% CI 1.08-5.15 for men within the lowest versus highest quartile of total 25OHD) additionally to hip fracture, serum 25OHD concentrations below 20 ng/mL (30 nmol/L) are related to the next risk of other osteoporotic fractures, including vertebral, wrist, and proximal humerus fractures in a very prospective cohort study of elderly Swedish men (mean age 71 years), serum 25OHD levels below 16 ng/mL (40 nmol/L) were related to a modestly increased risk for fracture (HR 1.65, 95% CI 1.09-2.49 within the aggregate, these observations suggest that calcium and D supplementation could protect bone by preventing bone loss and by healing subclinical osteomalacia. Although the optimal serum 25OHD concentration to keep up skeletal health isn’t firmly established, serum values exceeding 19 to 24 ng/mL (47.5 to 60 nmol/L) are supported by observational studies Randomized trial data — Evidence supporting the advantage of calcium and D supplementation in patients with osteoporosis comes largely from prospective, randomized, placebo-controlled trials Although variety of trials have reported a beneficial effect of calcium or calcium plus cholecarciferol on bone density in postmenopausal women and older men the information on fracture rates are more variable Some trials have reported a discount in fracture but large randomized trials haven’t shown any reduction in fracture risk with calcium plus viosterol In the most important of those trials (Women’s Health Initiative), however, subgroup analysis revealed that calcium and calciferol supplementation was related to reduced fracture incidence in those subjects who were most compliant The Women’s Health Initiative trial randomly assigned 36,282 postmenopausal women ages 50 to 69 years (not selected for low bone density or osteoporosis) to calcium (1000 mg/day) plus D (400 int. units/day) or placebo (personal supplementation of up to 1000 mg additional calcium and 600 units fat-soluble vitamin was also allowed, as was bisphosphonate, calcitonin, and hormone therapy use [over one-half of subjects were taking hormone therapy the subsequent results were seen: • After a mean follow-up period of seven years in a very subset of girls who had bone mass measurements performed, hip bone mineral density was 1.06 percent higher within the calcium-vitamin D group compared with the placebo group.

• The risk of hip fracture with calcium-vitamin D (intention-to-treat analysis) was not up to placebo although this wasn’t statistically significant (HR 0.88, 95% CI 0.72-1.08). However, when only compliant subjects were analyzed (predefined as people who took over 80 percent of medication), a big decrease in hip fracture was seen (HR 0.71, 95% 0.52-0.97).

• In all subjects, the danger of kidney stones was increased with calcium-vitamin D supplementation (HR 1.17. 95% CI 1.02-1.34). The trial had variety of limitations: a greater fracture reduction may need been seen if subjects had been selected on the premise of low bone density or low calcium/vitamin D intake at baseline. additionally, the high percentage of ladies taking hormone therapy may have made it difficult to determine an impression of the calcium-vitamin D on bone, and lastly, the ergocalciferol supplementation may are too low

Calcium versus D

— In many of those trials, it’s difficult to differentiate the effect of calcium from that of viosterol. Randomized trials of calcium only or cholecarciferol only have shown mixed results, likely because of differences in patient populations and study design. A meta-analysis of 5 trials comparing fat-soluble vitamin (400 to 1370 units/day) with placebo in over 14,500 elderly men and ladies reported that cholecarciferol supplementation alone failed to reduce fracture risk (RR 1.03, 95% CI 0.84-1.26) within the same review, a separate meta-analysis of 11 trials comparing calcium (500 to 1200 mg/d) plus cholecarciferol (300 to 1100 units/day) with placebo showed that combined supplementation reduced the danger for total fractures (RR 0.88, 95% CI 0.78-0.99 in a very subgroup analysis, the danger reduction was larger among institutionalized elderly than community dwelling individuals (RR 0.71 versus 0.89) Other meta-analyses of trials comparing calcium, vitamin D, or both with placebo or no treatment reported a beneficial reduction in fracture with calcium and calcium plus ergocalciferol but not with D alone Relative risk reductions for hip fracture ranged from 0.81 to 0.87 for combined calcium plus D supplementation These findings suggest that supplementation with both calcium and calciferol reduces the danger of fracture.


— The optimal dose of calcium and vitamin D is uncertain. during a number of trials that reported a beneficial effect of calcium on bone density in postmenopausal women and older men, calcium supplement doses ranged from 500 to 1200 mg daily Baseline calcium from diet varied from approximately 600 to 1000 mg daily. Thus, total (diet plus supplement) calcium intake ranged from approximately 1100 to 2000 mg daily. a good range of ergocalciferol doses were utilized in the clinical trials. a number of the trials were designed to review intermittent dosing of viosterol, specifically 100,000 units administered every three to four months whereas others used 400 units of cholecarciferol daily One meta-analysis of randomized trials didn’t show differential effects on fracture risk reduction based upon the dose of viosterol However, another analysis showed a big effect of vitamin D dose when the particular fat-soluble vitamin intake (rather than assigned fat-soluble vitamin dose) was calculated during this pooled analysis of patient level data from 11 randomized trials (31,022 persons, mean age 76 years) of oral viosterol supplementation, with or without calcium, compared with placebo or calcium alone, there was a major reduction in incidence of hip (RR 0.70, 95% CI

0.58-0.86) and nonvertebral (RR 0.86, 95% CI 0.76-0.96) fracture within the individuals with the very best calculated actual vitamin D intake (median 800 units daily, range 792 to 2000 units daily) compared with controls. There was no reduction in risk of hip fracture at actual intake levels but 792 units daily. only a few of the trials included within the meta-analysis provided information on baseline and follow-up serum 25-hydroxyvitamin D levels and, therefore, the optimal serum 25-hydroxyvitamin D concentration for fracture prevention couldn’t be established. In two placebo-controlled trials of high-dose (300,000 to 500,000 units) viosterol administered once yearly (without calcium supplementation), vitamin D didn’t reduce the chance of fracture In one in all the trials, the chance of falls and fracture was increased within the fat-soluble vitamin group (RRs 1.15, 95% CI 1.02-1.30 and 1.26, 95% CI 1.00-1.59 for falls and fracture, respectively) within the ergocalciferol group, the median 25OHD concentrations after one and three months were approximately 48 and 36 ng/mL (120 and 90 nmol/L), respectively. Based upon the meta-analyses discussed above, we recommend 1200 mg of calcium (total of diet and supplement) and 800 int. units of fat-soluble vitamin daily for many postmenopausal women with osteoporosis. Although the optimal intake (diet plus supplement) has not been clearly established in premenopausal women or in men with osteoporosis, 1000 mg of calcium (total of diet and supplement) and 400 to 600 int. units of vitamin D daily are generally suggested. We recommend not administering yearly high-dose (eg, 500,000 units) D. These recommendations are in step with the Institute of drugs Dietary Reference Intakes for calcium and vitamin Certain coexisting medical problems may alter these requirements. In patients at very high risk for fracture in whom there’s a clinical suspicion that the standard doses are inadequate (malabsorption, decreasing bone mass), measurement of 25OHD concentrations could also be necessary to make sure that supplementation is adequate. Commercial assays measure total 25OHD, but some labs report vitamin D2 (25OHD2) and D3 (25OHD3) values separately. The optimal serum concentration refers to the combined total. The optimal serum 25OHD concentration for skeletal health is controversial. The Institute of drugs supports 25OHD concentrations above 20 ng/mL (50 nmol/L) but not chronically exceeding 50 ng/mL (125 nmol/L) the next serum concentration could also be necessary for skeletal benefits, particularly in older individuals at greater risk. Thus, some patients require quite 800 units daily to take care of serum levels of 30 to 40 ng/mL (75 to 100 nmol/L Optimal serum 25OHD concentrations are discussed in additional detail elsewhere. Optimal intake may be achieved with a mixture of diet plus supplements. Calcium appears to be also absorbed from supplements as from milk and supplements were employed in the above trials demonstrating get pleasure from increased calcium intake. it’s likely, therefore, that supplements aren’t less effective than calcium found naturally in dairy products. it’s important for patients to remember that calcium and calciferol alone are probably insufficient to forestall bone loss although they’ll be beneficial in some subgroups (the elderly, those with low intake at baseline). ergocalciferol supplementation is important for variety of other reasons independent of bone health; these are reviewed separately .


— A rough method of estimating dietary calcium intake is to multiply the quantity of dairy servings consumed per day by 300 mg. One serving is 8 oz (240 mL) of milk or yogurt or 1 oz of bad luck. farmer’s cheese and frozen dessert contain approximately 150 mg of calcium per 4 oz (120 mL). Other foods during a well-balanced diet (dark green vegetables, some nuts, breads, and cereals) supply a median of 100 mg of calcium daily Some cereals, soy products, and fruit juices are fortified with up to 1000 mg of calcium. While it’s possible to estimate the quantity of calcium in other sources of dietary calcium like green vegetables and nuts, calcium absorption from these sources is more variable.

additionally, vegetables and nuts have much lower calcium content than dairy products in order that way more would wish to be consumed to fulfill daily requirements. Detailed lists of the calcium content of assorted foods are available from the US Department of Agriculture Calcium supplements or increased intake of dairy products should be recommended if dietary calcium intake is below recommended levels. If supplements are needed, it’s important to notice that the intake suggested above reflects the quantity of elemental calcium in supplements, not the entire calcium content. additionally, the overall intake of calcium (diet plus supplements) shouldn’t routinely exceed 2000 mg/day due to the chance of adverse effects ergocalciferol — within the u. s., commercially fortified milk is that the largest source of dietary ergocalciferol, containing approximately 100 int. units of calciferol per 8 oz Thus, cholecarciferol intake is estimated by multiplying the quantity of cups of milk consumed per day by 100. viosterol is additionally found in cod liver oil, but some fish oils also contain high doses of antiophthalmic factor, and so they’re not the most effective source of ergocalciferol Sunlight exposure also increases vitamin D concentrations. However, the employment of sunscreen products effectively blocks vitamin D synthesis. additionally, the skin of these older than 70 years old doesn’t convert D as efficiently as in younger individuals. Thus, fat-soluble vitamin supplements are generally necessary. The safe upper limit for calciferol is unclear but is above 2000 units daily.


— In patients requiring calcium and calciferol supplementation, a daily multivitamin is both convenient and economical. However, most multivitamins contain only 400 int. units of fat-soluble vitamin, which is insufficient, and not all individuals require or tolerate multivitamins .) Postmenopausal women with osteoporosis can even increase viosterol and calcium intake by taking plain ergocalciferol supplements (usually 400 units per tablet) and/or calcium supplements that also contain fat-soluble vitamin, usually 200 units per 500 mg or 600 mg of calcium. it’s important to notice that there’s not an instantaneous linear relationship between supplemental dosing and level of serum 250HD. Individuals with low levels at baseline (<10 ng/mL) generally have a rise in 250HD of 1.0 to 1.5 ng/mL for each 100 IU of vitamin D; however, individuals at levels above 20 ng/mL show an attenuated increase in serum 250HD (ie, usually 0.5 ng/mL for each 100 units). Calcium — the foremost widely available calcium supplements are carbonate and calcium citrate carbonate is cheapest and thus often a decent first choice. However, there are some limitations to its use compared with calcium citrate:

  • Calcium carbonate absorption is healthier when crazy meals; compared, calcium citrate is well absorbed within the fasting state and is best or equally absorbed compared with carbonate dotty a meal. this could be particularly important in patients with achlorhydria. Thus, it seems prudent to require carbonate with meals, since it’s often hard to grasp who has achlorhydria.
  • Calcium carbonate is additionally poorly absorbed in patients taking proton pump inhibitors or H2 blockers. We usually recommend calcium citrate as a primary line calcium supplement in these patients.
  • Many natural carbonate preparations like oyster shells or bone meal contain some lead, and tiny amounts are present in refined (antacid) carbonate or calcium citrate The low lead levels in calcium supplements are unlikely to be a health risk, because calcium blocks lead absorption Dosing  — The intake recommendations given above seek advice from the number of elemental calcium . As an example, carbonate is 40 percent elemental calcium, in order that 1250 mg of carbonate contains 500 mg of elemental calcium. The dose of elemental calcium is listed on most supplement labels. Calcium supplementation in more than 500 mg/day should be in divided doses. Higher individual doses are related to a plateau in calcium absorption that will prevent the attainment of positive calcium balance Side effects   — normally, concern that prime dietary calcium increases the chance of nephrolithiasis in otherwise healthy patients is unfounded, because the incidence of stone formation appears to be reduced in both men and ladies This issue is discussed well separately. However, calcium supplements are related to an increased risk of kidney stones . The Women’s Health Initiative (WHI) trial described above also reported an increased risk of kidney stones in postmenopausal women who were supplemented with calcium and cholecarciferol compared with placebo Other potential side effects of high calcium intake include dyspepsia and constipation. additionally, calcium supplements interfere with the absorption of iron and hormone and, therefore, these medications should be taken at different times. The effect of calcium supplementation on risk of upset is controversial There is also benefits of calcium supplementation on risk factors, like a discount in weight, pressure, and in serum cholesterol concentrations (of about 5 percent) in patients with mild to moderate hypercholesterolemia. .) within the WHI trial described above, 36,282 postmenopausal women ages 50 to 69 years were randomly assigned to calcium (1000 mg/day) plus fat-soluble vitamin (400 int. units/day) or placebo (personal supplementation of up to 1000 mg additional calcium and 600 units viosterol was also allowed) upset was a prespecified secondary outcome . At baseline, mean calcium intake (diet plus supplements) was approximately 1150 mg/day, and 54 percent of participants were taking non-protocol calcium supplements. After seven years, calcium plus viosterol supplementation had no significant effect on the incidence of myocardial infarct (confirmed in 411 and 390 women assigned to calcium/vitamin D and placebo, respectively; HR 1.05, 95% CI 0.91-1.20) or stroke (362 versus 377 strokes, HR 0.95, 95% CI 0.82-1.10). However, the findings of two meta-analyses evaluating calcium or calcium with or without ergocalciferol supplementation (eight and nine trials, respectively) raised some concern about an increased risk of infarct (MI) in patients randomly assigned to calcium versus placebo (166 versus 130 MIs, pooled relative risk 1.27, 95% CI 1.01-1.59) or calcium with or without D versus placebo (374 versus 302 MIs, RR 1.24, 95% CI 1.07-1.45 . The meta-analyses had several limitations. The trials within the meta-analyses weren’t designed to explore cardiovascular outcomes, which weren’t uniformly collected or adjudicated. Patient level data weren’t available from all the trials. In one in all the meta-analyses, only data from a subgroup of participants within the Women’s Health Initiative (those not taking personal calcium supplements at randomization), instead of all participants, were included within the analysis The baseline dietary calcium intake within the trials ranged from 750 to 1240 mg daily and therefore the addition of calcium supplements raised total intake over 1500 to 2000 mg daily in many patients, which is on top of recommended. Another meta-analysis evaluated the consequences of supplementation with calcium, vitamin D, or both on upset (CVD), including CVD death, nonfatal coronary cardiopathy or MI, and nonfatal stroke in a very pooled analysis of 4 trials, calcium supplementation failed to significantly increase the chance of CVD events compared with placebo (RR 1.14, 95% CI 0.92-1.41). In these trials, dietary intake of calcium ranged from 800 to 900 mg daily and also the dose of calcium supplements ranged from 600 to 1200 mg daily. during a pooled analysis of two trials (one of which was the Women’s Health Initiative and included data from all participants), combined vitamin D and calcium supplementation versus double placebos (RR 1.04, 95% CI 0.92-1.18) and ergocalciferol alone compared with placebo (RR 0.90, 95% CI 0.77-1.05) also failed to significantly increase the danger of CVD, and there was a suggestion of a benefit in CVD reduction with vitamin D alone. As within the meta-analyses described above, none of the trials were designed to assess the consequences of calcium or cholecarciferol on cardiovascular outcomes. A prospective cohort study (23,980 participants with mean follow-up of 11 years) published after the meta-analyses showed a big reduction in MI risk in patients with higher versus lower total dietary calcium intake (HR 0.69, 95% CI 0.50-0.94 for the third compared with lowest quartile of total dietary calcium intake) . in an exceedingly separate analysis using the identical cohort, there was a big increased risk of myocardial infarct in users versus nonusers of calcium supplements (HR 1.86, 95% CI 1.17-2.96). However, there have been only 20 events within the calcium group, which reduced the precision of the analysis. Thus, it’s unclear from the current data whether intake of dietary calcium versus calcium supplements confers different cardiovascular risks. Randomized trials of calcium and vitamin D supplementation with CVD events ascertained as a primary endpoint are required to see if calcium supplementation is related to an increased occurrence of those events . within the interim, we advise combined calcium and vitamin D supplementation, as reviewed above Vitamin D  — D is mostly easier to soak up than calcium and it should be taken together dose with or without food. the 2 commonly available varieties of fat-soluble vitamin supplements are ergocalciferol and cholecalciferol. Some but not all studies suggest that cholecalciferol (vitamin D3) increases serum 25OHD more efficiently than does ergocalciferol (vitamin D2 . additionally, ergocalciferol2 isn’t accurately measured all told vitamin D assays For these reasons, we recommend supplementation with cholecalciferol when possible, instead of ergocalciferol. Calcitriol is that the most active metabolite of ergocalciferol. It can frequently cause hypercalcemia and/or hypercalciuria, necessitating close monitoring and adjustment of calcium intake and calcitriol dose. Therefore, we don’t recommend calcitriol for fat-soluble vitamin supplementation in osteoporosis. However, calcitriol or other D analogs are a crucial component of therapy for secondary hyperparathyroidism in chronic nephrosis .)

 Adverse effects

— The intake at which the dose of D becomes toxic isn’t clear. In 2010, the Institute of medication defined the Safe Upper Limit for viosterol as 4000 int. units per day However, higher doses are sometimes required for the initial treatment of viosterol deficiency. .) it’s important to inquire about additional dietary supplements (some of which contain viosterol) that patients could also be taking before prescribing extra vitamin D [ 83 ]. Excessive D, especially combined with calcium supplementation, may cause hypercalcemia, hypercalciuria, and kidney stones. additionally, chronically high levels of 250HD (exceeding 40 and 50 ng/mL [100 and 125 nmol/L], respectively) are found in some association studies to be linked to a modest increase in risk of some cancers (eg, pancreatic) and mortality. and “Vitamin D and extraskeletal health”, section on ‘Mortality’ .) More studies are needed to define the upper level of serum 250HD that’s safe. Coexisting medical problems   — Many individuals with osteoporosis have underlying medical conditions that predispose to osteoporosis. Recommendations for calcium and viosterol supplementation may vary with the underlying condition

. fat-soluble vitamin deficiency

— viosterol deficiency may result from inadequate intake combined with lack of sun exposure, malabsorption, or genetic abnormalities in vitamin D metabolism. viosterol deficiency or insufficiency is commonly overlooked, unless 25OHD concentrations are measured. Commonly used antiresorptive agents, like bisphosphonates, could also be less effective in patients with occult cholecarciferol deficiency. additionally, hypocalcemia can occur in patients with D deficiency who are treated with bisphosphonates, particularly when administered intravenously, before repletion of fat-soluble vitamin Individuals with ergocalciferol deficiency generally require higher doses of viosterol initially, followed by maintenance doses as described above. The treatment of calciferol deficiency is reviewed separately Primary hyperparathyroidism   — Adequate dietary calcium (800 to 1000 mg daily) and viosterol supplementation (400 to 600 units daily) is inspired for patients with primary hyperparathyroidism. Cautious calcium supplementation is safe in individuals with poor dietary intake. Patients with overt calciferol deficiency may have more clinically significant hyperparathyroidism and will require cautious supplementation with higher doses of vitamin D Underlying gastrointestinal disease   — Patients with malabsorption or short-bowel syndrome may have beyond normal calcium and calciferol requirements thanks to diminished calcium absorption. This problem can occur even with relatively minor disruption of gastrointestinal function, as in patients who have undergone gastrectomy Several factors can contribute to the malabsorption of calcium in these patients:

  • Reduced gastric acidity and mild generalized malabsorption thanks to impaired mixing of food with pancreatic secretions and decreased gut transit time.
  • Binding of calcium to fatty acids in patients with steatorrhea
  • Vitamin D deficiency because of both malabsorption and also the tendency to avoid milk Optimal calcium and D supplementation must be determined empirically and must be adjusted so as to normalize the serum concentrations of calcium, phosphate, alkaline phosphatase, 25OHD, and endocrine, and 24-hour urinary calcium excretion The American Gastroenterological Association (AGA) technical review and guideline for osteoporosis in gastrointestinal diseases yet as other AGA guidelines, will be accessed through Proton pump inhibitor therapy  — carbonate is poorly absorbed in patients taking proton pump inhibitors or H2 blockers. We usually recommend calcium citrate as a primary line calcium supplement in these patients. Diuretic therapy  — Concomitant administration of diuretics can influence calcium balance. Loop diuretics increase calcium excretion, while thiazide diuretics have a hypocalciuric effect that may protect against calcium stones and possible bone loss. The effect of diuretics on optimal dietary calcium intake isn’t known. monogenic disorder   — Patients with advanced monogenic disorder are usually deficient in ergocalciferol, and that they require quite the standard recommended dose for young adults (eg, over 400 int. units/day).

Granulomatous diseases

— Individuals with granulomatous diseases, like sarcoidosis, are often treated with glucocorticoids and thus have an increased risk of osteoporosis. However, they also tend to own hypercalcemia and hypercalciuria because of extrarenal production of calcitriol by activated macrophages and consequent increased intestinal absorption of calcium In patients with sarcoidosis and osteoporosis, serum and urinary calcium and ergocalciferol concentrations must be carefully monitored if supplements are required



— UpToDate offers two varieties of patient education materials, “The Basics” and “Beyond the fundamentals.” the fundamentals patient education pieces are written in plain language, at the 5 th to six th grade reading level, and that they answer the four or five key questions a patient might need a couple of given condition. These articles are best for patients who need a general overview and preferring short, easy-to-read materials. Beyond the fundamentals patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the ten th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to the current topic. We encourage you to print or e-mail these topics to your patients. (You also can locate patient education articles on a spread of subjects by searching on “patient info” and also the keyword(s) of interest.) SUMMARY and proposals   — Adequate calcium and cholecarciferol intake may end up in positive calcium balance and a discount within the rate of loss of bone; the effect upon fracture risk is a smaller amount clear, although combined calcium and calciferol supplementation appears to cut back fracture risk. Calcium and viosterol supplementation are relatively inexpensive and appear reasonable to recommend in patients with a coffee dietary intake.

  • We suggest calcium and D supplementation in patients with osteoporosis and inadequate dietary intake In postmenopausal women, 1200 mg of elemental calcium daily, total diet plus supplement, and 800 int. units of calciferol daily are suggested. Although the optimal intake (diet plus supplement) has not been clearly established in premenopausal women or in men with osteoporosis, 1000 mg of calcium (total diet plus supplement) and 400 to 600 int. units of calciferol daily are generally suggested. The dose of calcium and cholecarciferol may vary in individuals with coexisting medical conditions.
  • Individuals with cholecarciferol deficiency require higher doses of ergocalciferol. The evaluation and treatment of fat-soluble vitamin deficiency are reviewed separately
  • In most people, carbonate loving meals is adequate for supplementation and is inexpensive. However, we recommend calcium citrate in patients taking proton pump inhibitors or H2 blockers or who have achlorhydria
  • We suggest cholecalciferol (vitamin D3), when available, instead of ergocalciferol (vitamin D2) for calciferol supplementation
  • The total intake of calcium (diet plus supplements) mustn’t routinely exceed 2000 mg/day. The safe upper limit for D is 4000 int. units daily
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