What is the difference between acute and chronic pem

The human body needs energy and nutrients to function. If food intake is inadequate, the body begins to break down body fat and muscle, the metabolism begins to slow down, thermal regulation is disrupted, the immune system is weakened, and kidney function is impaired. Decreased food consumption, increased energy expenditure, and illness result in a poor nutritional state known as malnutrition or undernutrition. One randomized study evaluated the effect of total parenteral nutrition in 16 malnourished elderly patients.

In conclusion, many studies have shown that nutritional treatment of PEM associated with multiple disorders in the elderly can yield positive effects on body composition, and in some cases on muscular strength, well-being, and immune function. Although treatment recommendations should be based on the results of RCTs, in some aspects, nutritional treatment is an exception to this scientific truism. We do not need randomized studies to validate the life-sustaining value of a nutrient supply in both healthy and sick individuals.

However, how nutritional treatment should be pursued and evaluated in connection with imminent or manifest malnutrition associated with an existing disorder is not clear. Disease-associated malnutrition is caused in part by disease-activated biochemical and physiologic mechanisms, including a systemic inflammatory response and neurohormonal adaptations , that affect the individual's appetite, the body's tissue composition, and the ability of the metabolic systems to metabolize energy and nutrients.

In most cases these pathophysiologic changes are adaptive and homeostatic. Nutritional therapy interacts with the metabolic processes specific to the disorder and under such conditions nutritional therapy must be viewed in a broader medical context. As this literature review shows, our current knowledge is insufficient to provide a firm scientific basis for recommendations on how nutritional treatment should be formulated in most of the reviewed disease groups.

Although many studies were performed, the results were heterogeneous. The definition of PEM varied between studies, which is a logical effect of there being no generally accepted definition of the condition. Several studies were limited by insufficient and widely varying patient data, short treatment periods, and a lack of clinically relevant outcome variables. Moreover, the results are difficult to compare and interpret because of the various nutritional therapies used.

There are serious methodologic problems in performing randomized controlled nutritional treatment studies. Examples include uncertain adherence to the treatment and the existence of several other concurrent, interacting treatments. In addition, the results are difficult to monitor because the natural course of the chronic disorder is often the cause of the malnutrition. Positive effects can be difficult to detect because of the complexities that exist in nutritional treatment.

One potential weakness in most treatment studies is that the total energy intake can seldom be specified. Elderly patients' ability to follow a prescribed nutritional intake varies widely , , Treatment with nutritional supplements can reduce habitual intake as a result of effects on the appetite or abdominal side effects 24 , 35 , , , In contrast, several studies showed that supplementation or enrichment of the diet does improve nutrient intake 89 , , , , , , — In a retrospective study, the use of supplements in nursing homes was described as a nonspecific intervention for weight loss with no regard to diagnoses and management of underlying problems, amount of supplement consumed, and outcome Also unclear is the degree to which the quality of the supplemented fat affects health other than being a high energy source.

Today, meals are usually energy enriched by adding dairy products, ie, saturated fatty acids. Further evaluation is needed to determine whether this is associated with negative effects, such as increased thrombogenic activity. An important consideration is the relevance of treatment-induced increases in anthropometric or biochemical variables.

Weight loss and hypoalbuminemia are both strongly correlated with increased mortality in sick persons. However, the causality relations are often unclear, ie, does the patient die from or with reduced weight or low serum albumin? It is not certain that a nutrition-induced increase in anthropometric and biochemical variables improves the patient's prognosis, or that functional capacity or life quality is amended.

A balanced nutritional treatment affects the body composition in a specific time sequence. First, the total body fluid volume rises, then the fat, and finally the lean body mass, ie, muscle and protein mass , An important aim of nutritional treatment is to restore the lean body mass.

In many of the reviewed studies, however, the nutrition treatment led primarily to increased fat storage. On the other hand, an improvement in clinical function does not have to be related to increased weight or size of body compartments because nutritional treatment can affect an organ's function faster than its size and mass Several lines of evidence indicate that systemic inflammation is one delineator of nonresponse to nutrition treatment 41 , , We cannot ignore the possibility that even optimal oral, enteral, or parenteral nutrition may have only a limited potential to improve the health of malnourished chronically ill patients, particularly if the malnutrition is linked to inflammation.

Pharmacologic modulation of the inflammatory response, by use of substances such as megestrol acetate, thalidomide, pentoxifylline, and dronabinol, may develop as supplemental methods to promote anabolism and appetite and to achieve growth of lean body mass. Physical exercise , — and anabolic or growth hormone therapy may prove to be further complementary treatments. We reviewed 90 nutrition treatment studies, 50 of which were RCTs. Some of the overall effects are summarized in Table 8.

Some of these studies did not have enough power to answer the question they addressed. One small study reported that growth hormone may be deleterious in severely ill heart failure patients This is an important consideration in light of a recent report of increased mortality in critically ill patients treated with growth hormone Otherwise, none of the studies we summarized showed any serious side effects.

Number of nutrition intervention trials with positive effects or no effect in patients with chronic obstructive pulmonary disease COPD , with chronic heart failure, during rehabilitation after hip fracture, or with chronic renal failure, and in elderly patients with multiple disorders 1.

OT, observational trial controlled and uncontrolled studies ; RCT, randomized controlled trial. Even though many factors in the interpretation of the reviewed studies are uncertain, the available treatment data indicate that nutritional supplements, either alone as balanced or protein-rich liquid nutrient drinks or in combination with hormonal administration, can have positive effects when given to chronically ill, nonmalignant patients with manifest PEM or at risk of PEM.

In malnourished patients with chronic obstructive pulmonary disease, positive treatment results such as improved respiratory function are seen.

However, these results are not homogeneous. In elderly women after hip fractures, liquid oral supplementation particularly protein-rich formulas promotes rapid rehabilitation. In elderly persons with multiple disorders, nutrition treatment results in increased functional capacity. The results of several trials including malnourished patients with chronic renal failure imply positive effects on anthropometric and biochemical measures especially when hormonal treatment is given , whereas few clinical outcome data were provided.

The effectiveness of PEM treatment in stroke, dementia, chronic heart failure, and rheumatoid arthritis cannot be measured because of a striking lack of published studies in these areas.

Deductions similar to ours were drawn in a recently published meta-analysis of 32 studies of randomly assigned patients who received oral or enteral dietary supplements In this meta-analysis, however, there were no indications that the treatment advantages were limited to specific disease categories. We conclude that there is a great need for randomized controlled preferably placebo-controlled long-term studies of the effects of defined nutritional intervention programs for certain PEM conditions associated with both specific and multiple disorders.

Along with determining biochemical and anthropometric variables, these studies should focus on determining clinically relevant outcomes such as morbidity, functional capacity, health-related quality of life, hospitalization periods, and mortality.

In addition, we require experimental and randomized treatment studies to develop and fine-tune pharmacologic methods to modulate systemic inflammatory responses and to stimulate anabolic processes and appetite.

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