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.

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

Dietetic treatment of type 2 diabetes for overweight

obese people Clinical Guide for Clinical Nutrition of Type 2 Diabetes Overweight and Obese People

This guide aims to enhance clinical practice that leads to the best medical service in order to obtain optimum results against diabetes, which is a brief guide directed to guide overweight and obese adults with diabetes in particular. Within the field of work of specialized medical dietitians in diabetes, in addition to the specialization of psychological counseling, social counseling, therapeutic physical sports, educated physiotherapists, as well as general and specialized doctors and nurses. According to the leading diabetes specialist centers in the world, every diabetic patient needs evaluation – in addition to the clinical medical evaluation – in terms of his nutritional and metabolic needs, the nature of his metabolic deviation interfering with diabetes, the importance of identifying therapeutic goals related to obesity and nutrition, unhealthy lifestyle adjustments, and physical activity, and the gradual approach to achieve medical therapeutic dietary recommendations.

General Directory

There are strong evidences that weight loss improves the response to insulin and blood sugar control and levels of blood lipids and blood pressure in patients with type 2 diabetes, and also reduces the risk of developing an explicit type 2 diabetes condition in pre-diabetes and high-risk groups of type 2 infection. To choose the appropriate therapeutic medical approach for the patient, it is preferable to refer to the therapeutic nutritionist to assess the patient’s nutritional habits and physiological and medical needs, integrate the nutritional adjustments into the patient’s medical and therapeutic lifestyle and work towards achieving the desired treatment goals.

The therapeutic priorities of this target group of patients include the following elements:

1 – Weight loss

2 – Determination of meal contents of carbohydrates and distribution of daily carbohydrates on meals in fixed quantities in treatments with fixed doses of insulin.

3 – Taking into account the therapeutic dietary considerations related to the diseases that may accompany diabetes, such as high arterial tension, blood lipids and cholesterol.

The relative table of the main components of the daily food is listed later as a general guide in therapeutic feeding, and some adjustments are made according to the patient’s condition, metabolic, satisfaction, and physiological needs, and taking into account some conditions of his own taste in food. All of that is done by a specialized therapeutic nutritionist, according to an action plan that schedules the dates of reassessment and modification of the therapeutic food plan according to clinical and laboratory standards that include: blood pressure, A1c, recurrence of hypoglycaemia / high blood sugar accidents, hyperlipidemia, and daily blood sugar measurements. In addition to checking the sodium and potassium blood ions, and the vegetarian patients.

Weight loss

  • It is necessary to design and develop a systematic plan for lifestyle adjustments that includes changes in daily nutrition, physical activity, and unhealthy lifestyle behaviors with the goal of gradually and healthy weight loss (• the best rate of weight loss is gradually 5 – 1 kg per week or in two weeks) This is done by reducing the daily intake of calories by 250 – 500 calories (1C), and the total daily calories should not be less than 1000-1200 calories for women, and 1200-1600 for men, and determination of the appropriate daily calories depends on the nutritionist’s evaluation of the patient’s daily intakes. (1) • Reducing 5-10% of the patient’s weight provides us with a significant improvement in controlling blood sugar in diabetics, and helps prevent the development of individuals with early diabetes in the pre-diabetes condition. The amount of weight loss depends on the condition of each patient and their data, and progressively proceeds until the appropriate BMI is achieved and / or shared with the amount of achievement of other treatment goals. (It is necessary to direct patients of this target group to the therapeutic and educated dietitians to teach them how to adjust the food rations and help them in practice, which is an effective way of managing weight) Patients should be provided with experiences in alternatives to preserved food designed for weight loss called (replacement meal) under the supervision of a nutritional specialist if they want to use them as alternatives to regular meals.

(With attention to the fact that they contain big amounts of potassium, and the need to reset medications that reduce blood sugar • in spite of the fact that stomach bariatric surgery may result in the nutritional and medical risk to the patient, it is still an effective option when used according to its needs) such as a mass index Body BMI> kg / m², or BMI> kg / m² with other participatory diseases in the patient ()

Till now, there is a limited evidence supporting recommendations for gastric bypass for BMI> kg / m² even if they have type 2 diabetes.


Large food ingredients



There is general agreement on the importance of the quality of fat as well as its amount, and it is recommended that the total fat intake per day be less than 35% of the total daily calories. (2B) • The amount of saturated fat is set> 7% of the total daily calories. (1B) • The amount of mono-bonded and polyunsaturated fats remaining is equivalent to the total recommended fat calories. (2B) • The amount of cholesterol in the food is determined> 300 mg / day for people with LDL cholesterol> mg / dl. 1C


Eat mono- and polyunsaturated fat (such as olive oil, nuts / seeds, avocado). (1B) • Eat fish types rich in fatty acids (omega-3) (120 g salmon, trout, sardines, tuna) twice per week as a good source of omega-3 fatty acids. 1B


Not recommended

For foods rich in saturated fats such as beef, ribs, whole milk products, and rich milk products (creamy and liquid cooked cheese, full-fat milk and milk) • Foods containing trans fats (fast food, pastries and baked goods prepared for commercial circulation, and some Types of margarine like ghee. Foods rich in cholesterol such as (egg yolks, and organs of the guts of animals such as the liver, marrow, and drops)



Daily fines

The daily protein intake should not be less than 2.1 g / kg of adjusted body weight (ABW) Weight Body Adjusted = ideal weight + IBW (weight body Ideal 25.0). Current weight – ideal weight. This amount is generally equivalent to 20- 30% of the total daily calories. (1B) There are no reliable scientific data that support increasing the daily intake of protein to 2 g / kg of adjusted body weight ABW • Available data confirm that eating protein portions in the meal helps to feel fullness. Reducing the content of meals, which increases the feeling of hunger), as a moderate increase in the protein content of the meal decreases the appetite for food, and this helps to continue Use weight (2B) and protein intake also helps reduce muscle mass loss in the body. (2B)


Eat fish meat, skinless chicken meat, skimmed or low-fat dairy products, nuts, seeds, and legumes.


Not recommended

  • Sources of protein rich in saturated fats (cow and lamb, ribs, pork, full-fat dairy products) in relation to these nutritional sources with a high risk of cardiovascular disease.

Diabetics with kidney disease

Although decreasing the total calories consumed per day will also decrease the amount of proteins consumed, the kidney patients must seek advice from the kidney specialist before increasing the total or the ratio percentage of protein in their diet.) • Rationing in protein is no longer recommended


The daily diet of diabetic nephropathy patients and restricting them to less than 8,0 g / kg of weight, as it was found that this does not change blood sugar control or coronary heart risk criteria, and it has no role affecting the renal impairment of the renal renal function in patients. A




The percentage of carbohydrates in the total daily caloric intake is 40-45 (1% .C) • The minimum carbohydrate for daily feeding must be 130 grams (1C) Patient

Considerations for glucose indicator / carbohydrate loading and glucose loading

The rules for index glycemic and load glycemic are important factors that the patient must know and care for to follow in daily food when choosing carbohydrate foodstuffs • It is recommended to choose foods with low glucose indicator. 2B) For example: whole grains, legumes, fruits, veggies, most vegetables


Eating vegetables, fruits, legumes, whole grains, and processed grains is recommended to be kept to a minimum (not removed from the rest of its dietary fibers).

Not recommended

Table sugar, crushed purified starch, industrially processed fiber-free grains, starchy foods, sugary drinks, pasta of various kinds, white bread, white rice (2B) • Low-fiber cereals (peeled) and white potatoes can be eaten in limited quantities (2B)


Dietary Fibers

It is recommended to eat 14 grams of fiber / 1000 calories (equivalent to 35-35 grams / day), (1B) • If a well tolerated patient can eat 50 grams of dietary fibers to improve high blood sugar levels after a meal. (2A) • Fibers in uncooked foods such as vegetables, fruits, seeds, nuts, and legumes are good to eat but need to take fibrous supplements with them such as psylium, resistant starch, and glucan beta.

Fine nutritional ingredients


It is recommended that the daily intake of sodium> 2300 mg) equal to one teaspoon of salt (/ day. 1A) • It is recommended to reduce the amount to 1500 mg / day for people over the age of 50 years, including patients with chronic kidney disease. (2B) • It is advised to recommend the patient to gradually reduce salt intake.


  • It is recommended that the daily intake of potassium is 4700 mg unless the patient has a problem with the excretion of potassium • Potassium helps to neutralize the intake of sodium by increasing the activation of sodium excretion mechanisms through the kidney • Foods rich in potassium include bananas, mushrooms, spinach and almonds in addition to Pan fruits and vegetables

Nutritional supplements

For some patients without nutritional deficiency and malnutrition, data on this topic do not support the use of vitamins and mineral electrolytes to improve blood glucose control or the use of herbal supplements or spices to enhance blood sugar control


Non – nutritive sweeteners

The U.S. Food and Drug Administration has stated that it is safe to use all artificial non-nutrient sweeteners in moderate quantities daily (e.g. one diet soda can per day), while artificial non-household sweeteners can be used in a larger amount daily

Life behavioral modifications and physical physical activity

Physical activity must be included within the medical nutritional prescription, as increased physical musculoskeletal activity is a component integrated in any weight-loss program, as well as it raises the benefits of controlling blood sugar to the upper limits, and contributes to the prevention of cardiovascular disease or cerebral. (1B) • Mild physical exercise is required at least 60-90 minutes five times a week at least, as this leads to weight loss, unless the patient has an indication for this effort in timing or intensity. (1B) • Physical activity should be a combination of strength, flexibility, and cardiovascular revitalization exercises, to achieve or increase the muscle mass in the body.