今日の臨床サポート

栄養管理(在宅医療)

著者: 小野沢滋 みその生活支援クリニック

監修: 和田忠志 いらはら診療所 在宅医療部

著者校正/監修レビュー済:2021/01/28
参考ガイドライン:
  1. アメリカ静脈経腸栄養学会(ASPEN):Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients, JPEN vol 26(1) supplement 2002
  1. 厚生労働省「日本人の食事摂取基準」(2015年版)
  1. 厚生労働省:(「日本人の食事摂取基準」(2020版)策定検討会報告書(案)
患者向け説明資料

概要・推奨   

  1. 在宅で最も必要な栄養管理は低栄養への対処[1]低栄養状態は筋肉減少症(サルコペニア)を悪化させ、ADLの低下を加速させる。そのため早期発見、早期介入が重要である。ただし、その際に介入すべきかどうかの判断はあくまで患者本人もしくは意思決定代理者と十分に話し合った上でなされる必要がある(推奨度2
  1. 通常、必要栄養量は体重×25~30Kcalを目安にし、タンパク量は1.0g/kgを初期の目標とする[2]。体重1kgの増減が熱量約7,000Kcalの過不足に相当する。簡易的にはこのことを用いて栄養量の調整を行うとよい(推奨度2)
  1. 人工栄養を開始するのであれば、経腸栄養を最優先に考えること。(推奨度1)
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
小野沢滋 : 特に申告事項無し[2021年]
監修:和田忠志 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 栄養支援の開始に当たって、本人・家族の意志を重視する必要性を記載した。
  1. 胃瘻造設件数が半減し、中心静脈栄養、経鼻胃管が増加傾向にある現状を考慮し、従来経管栄養の導入に特化していた記載を、人工栄養の開始と不開始、また人工栄養を行うに当たっての投与経路選択についての記載に変更した。
  1. 高齢者の食事制限と、低栄養のリスクについての考え方を記載した。

まとめ

まとめ  
疫学:
  1. 在宅医療を受けている多くの患者が要介護状態の高齢者でそのうち30%以上が低栄養状態にある[3]。また、現在、安定していても要介護状態の高齢者は嚥下障害や認知障害を伴っており、容易に栄養状態が悪化しやすい。摂取カロリー不足による蛋白・エネルギーの低栄養状態はprotein energy malnutrition(PEM)と呼ばれ、るいそうや意識障害、筋力低下などの障害を来すことがある。
  1. 在宅で最も必要な栄養管理は低栄養への対処[1]で,低栄養状態は筋肉減少症(サルコペニア)を悪化させ、ADLの低下を加速させる。そのため早期発見、早期介入が重要である。ただし、その際に介入すべきかどうかの判断はあくまで患者本人もしくは意思決定代理者と十分に話し合った上でなされる必要がある。
  1. 高齢者では過体重傾向の方が予後がよい可能性が指摘されており、無理に減量を進める必要はなく、むしろ痩せに注意すべきである[4]
  1. 現在のところ、ASPENなどから提示されているものを含めいくつかの低栄養状態の定義があるが、統一されておらず、したがって低栄養状態の頻度の報告は報告によってさまざまである[1][5][6][7][8][9][10][11][12]
 
低栄養状態(Protein Energy MalnutritionPEM)の分類
  1. 通常、摂取カロリー不足による蛋白・エネルギーの低栄養状態はprotein energy malnutrition(PEM)と呼ばれ、いくつかの病態に分類される。古くから飢餓の子どもたちにみられる低栄養の分類が成人にも当てはめられてきた。
  1. 長期間にわたり摂取量全体が不足して、著明なるいそうがみられるがアルブミン値は保たれているマラスムス(marasmus)と、蛋白摂取が足りず、もしくは異化が亢進して起きる低栄養で、浮腫があるためるいそうは目立たずアルブミンが著明に低値となるクワシオルコル(kwashiorkor)である。また、るいそうと浮腫、低蛋白が合併することも成人ではまれではなく、marasmic kwashiorkorといわれることもある。
  1. 2012年に米国静脈経腸栄養学会 (American society of parenteral and enteral nutrition、ASPEN)から出された成人の低栄養の記述についての声明[13]では、低栄養の原因に基づいて、①飢餓による低栄養(starvation related malnutrition)、②慢性疾患関連低栄養(chronic disease-related malnutrition)、③急性疾患・外傷関連低栄養(acute disease or injury-related malnutrition)――に分類されており、よりわかりやすく、かつ臨床上での対処に直結した形になっている。今後はこちらの分類が多く用いられると考える。
 
栄養管理:
  1. 栄養管理は、スクリーニングで問題のある症例について、①栄養状態の評価、摂取栄養量の計測、②必要栄養量と不足栄養量の算出、③投与方法・投与経路の検討、④投与計画の実施、⑤モニタリング→栄養状態の評価、というように5つのステップを繰り返し行う事によって成り立つ。
  1. 栄養管理において、最も難しいのは立てた栄養計画を誰がどのように実行するのか、という点である。これを実行するためには、栄養士、介護職との多職種連携が必須である。
  1. また、在宅医療の対象となる進行疾患や高齢者の栄養管理において、エビデンスレベルが高いものは栄養補助食品などの使用などに限られている[14][15]。また、効果については個別性が高い。その限界を見極め、無理な介入は慎むようにすべきである。
  1. 人工栄養の選択についての話し合いについては、十分に情報を提供した上で、本人の意思を最大限尊重するべきである。また、不開始の希望がある場合には、厚生労働省の『人生の最終段階における医療・ケアの決定プロセスに関するガイドライン』を参照し、倫理的な配慮を行う必要がある。
 
鑑別疾患表:
急性炎症
  1. 急性疾患・外傷に関する栄養障害(急性の侵襲):感染症、外傷、頭部外傷などに関する栄養障害など
慢性炎症
  1. 臓器不全、関節リウマチ、代謝からみたサルコペニアなどに関する栄養障害など
摂取障害
  1. 栄養摂取障害に関する栄養障害(飢餓)-食欲不振や神経性食欲不振症による慢性的な栄養摂取障害など

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文献 

著者: Matthias J Kaiser, Jürgen M Bauer, Christiane Rämsch, Wolfgang Uter, Yves Guigoz, Tommy Cederholm, David R Thomas, Patricia S Anthony, Karen E Charlton, Marcello Maggio, Alan C Tsai, Bruno Vellas, Cornel C Sieber, Mini Nutritional Assessment International Group
雑誌名: J Am Geriatr Soc. 2010 Sep;58(9):1734-8. doi: 10.1111/j.1532-5415.2010.03016.x.
Abstract/Text OBJECTIVES: To provide pooled data on the prevalence of malnutrition in elderly people as evaluated using the Mini Nutritional Assessment (MNA).
DESIGN: Retrospective pooled analysis of previously published datasets.
SETTING: Hospital, rehabilitation, nursing home, community.
PARTICIPANTS: Four thousand five hundred seven people (75.2% female) with a mean age of 82.3.
MEASUREMENTS: The prevalence of malnutrition in the combined database and in the four settings was examined.
RESULTS: Twenty-four data sets with information on full MNA classification from researchers from 12 countries were submitted. In the combined database, the prevalence of malnutrition was 22.8%, with considerable differences between the settings (rehabilitation, 50.5%; hospital, 38.7%; nursing home, 13.8%; community, 5.8%). In the combined database, the "at risk" group had a prevalence of 46.2%. Consequently, approximately two-thirds of study participants were at nutritional risk or malnourished.
CONCLUSION: The MNA has gained worldwide acceptance and shows a high prevalence of malnutrition in different settings, except for the community. Because of its specific geriatric focus, the MNA should be recommended as the basis for nutritional evaluation in older people.

© 2010, Copyright the Authors. Journal compilation © 2010, The American Geriatrics Society.
PMID 20863332  J Am Geriatr Soc. 2010 Sep;58(9):1734-8. doi: 10.1111/j・・・
著者: ASPEN Board of Directors and the Clinical Guidelines Task Force
雑誌名: JPEN J Parenter Enteral Nutr. 2002 Jan-Feb;26(1 Suppl):1SA-138SA.
Abstract/Text
PMID 11841046  JPEN J Parenter Enteral Nutr. 2002 Jan-Feb;26(1 Suppl):・・・
著者: Lisa Söderström, Andreas Rosenblad, Eva Thors Adolfsson, Anja Saletti, Leif Bergkvist
雑誌名: Clin Nutr. 2014 Apr;33(2):354-9. doi: 10.1016/j.clnu.2013.06.004. Epub 2013 Jun 13.
Abstract/Text BACKGROUND & AIMS: There is an association between malnutrition and mortality. However, it is uncertain whether this association is independent of confounders. The aim of the present study was to examine whether nutritional status, defined according to the three categories in the full Mini Nutritional Assessment (MNA) instrument, is an independent predictor of preterm death in people 65 years and older.
METHODS: This prospective cohort study included individuals aged ≥65 years who were admitted to hospital between March 2008 and May 2009 and followed-up after 50 months (n = 1767). Nutritional status was assessed with the MNA, and possible risk factors associated with malnutrition were recorded during participants hospital stay. Main outcome measure was overall survival.
RESULTS: Based on the MNA definitions, 628 (35.5%) were well-nourished, 973 (55.1%) were at risk of malnutrition, and 166 (9.4%) of the participants were malnourished at baseline. During the follow-up period 655 (37.1%) participants died. At follow-up, the survival rates were 75.2% for well-nourished participants, 60.0% for those at risk of malnutrition, and 33.7% for malnourished participants (p < 0.001). After adjusting for confounders the hazard ratios (95% CI) for all-cause mortality were 1.56 (1.18-2.07) in the group at risk of malnutrition and 3.71 (2.28-6.04) in the malnourished group.
CONCLUSIONS: Nutritional status defined according to the three categories in the full MNA independently predicts preterm death in people aged 65 years and older. These findings are clinically important and emphasise the usefulness of the MNA for screening of nutritional status.

Copyright © 2013 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
PMID 23810625  Clin Nutr. 2014 Apr;33(2):354-9. doi: 10.1016/j.clnu.20・・・
著者: Charles Mueller, Charlene Compher, Druyan Mary Ellen, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors
雑誌名: JPEN J Parenter Enteral Nutr. 2011 Jan;35(1):16-24. doi: 10.1177/0148607110389335.
Abstract/Text
PMID 21224430  JPEN J Parenter Enteral Nutr. 2011 Jan;35(1):16-24. doi・・・
著者: M Ferguson, S Capra, J Bauer, M Banks
雑誌名: Nutrition. 1999 Jun;15(6):458-64.
Abstract/Text Nutrition screening identifies individuals who are malnourished or at risk of becoming malnourished and who may benefit from nutrition support. The aim of this study was to develop a simple, reliable and valid malnutrition screening tool that could be used at hospital admission to identify adult acute patients at risk of malnutrition. The sample population included 408 patients admitted to an Australian hospital, excluding pediatric, maternity, and psychiatric patients. The ability of various nutrition screening questions to predict subjective global assessment (SGA) were examined in contingency tables. The combination of nutrition screening questions with the highest sensitivity and specificity at predicting SGA was termed the malnutrition screening tool (MST), and consisted of two questions regarding appetite and recent unintentional weight loss. Subjects who were at risk of malnutrition according to the MST had significantly lower mean values for the objective nutrition parameters (except immunologic parameters) and longer length of stays than subjects who were not at risk of malnutrition. Therefore convergent and predictive validity of the MST was established. The interrater reliability of the malnutrition screening tool was high (93-97%). The MST is a simple, quick, valid, and reliable tool which can be used to identify patients at risk of malnutrition.

PMID 10378201  Nutrition. 1999 Jun;15(6):458-64.
著者:
雑誌名: N Engl J Med. 1991 Aug 22;325(8):525-32. doi: 10.1056/NEJM199108223250801.
Abstract/Text BACKGROUND: We undertook this study to test the hypothesis that perioperative total parenteral nutrition (TPN) decreases the incidence of serious complications after major abdominal or thoracic surgical procedures in malnourished patients.
METHODS: We studied 395 malnourished patients (99 percent of them male) who required laparotomy or noncardiac thoracotomy. They were randomly assigned to receive either TPN for 7 to 15 days before surgery and 3 days afterward (the TPN group) or no perioperative TPN (the control group). The patients were monitored for complications for 90 days after surgery.
RESULTS: The rates of major complications during the first 30 days after surgery in the two groups were similar (TPN group, 25.5 percent; control group, 24.6 percent), as were the overall 90-day mortality rates (13.4 percent and 10.5 percent, respectively). There were more infectious complications in the TPN group than in the controls (14.1 vs. 6.4 percent; P = 0.01; relative risk, 2.20; 95 percent confidence interval, 1.19 to 4.05), but slightly more noninfectious complications in the control group (16.7 vs. 22.2 percent; P = 0.20; relative risk, 0.75; 95 percent confidence interval, 0.50 to 1.13). The increased rate of infections was confined to patients categorized as either borderline or mildly malnourished, according to Subjective Global Assessment or an objective nutritional assessment, and these patients had no demonstrable benefit from TPN. In contrast, severely malnourished patients who received TPN had fewer noninfectious complications than controls (5 vs. 43 percent; P = 0.03; relative risk, 0.12; 95 percent confidence interval, 0.02 to 0.91), with no concomitant increase in infectious complications.
CONCLUSIONS: The use of preoperative TPN should be limited to patients who are severely malnourished unless there are other specific indications.

PMID 1906987  N Engl J Med. 1991 Aug 22;325(8):525-32. doi: 10.1056/N・・・
著者: Y Ingenbleek, Y A Carpentier
雑誌名: Int J Vitam Nutr Res. 1985;55(1):91-101.
Abstract/Text A new prognostic inflammatory and nutritional index is described allowing the correct follow-up of most pathological conditions. Discriminant analysis of eleven currently utilized blood markers of the phlogistic reaction and of the nutritional status has afforded the selection of the two most reliable acute-phase reactants (orosomucoid and C-reactive protein) and visceral proteins (albumin and prealbumin). These parameters are combined in a simple formula which consistently and accurately stratifies critically ill patients by risk of complications or death. The grading system is determined by a rapid and inexpensive micromethod encompassing both infectious and nutritional poles of the disease spectrum within a self-explanatory scale. The scoring system provides a more sensitive tool for the diagnosis and prognosis of stressed patients than any other method available to date.

PMID 3922909  Int J Vitam Nutr Res. 1985;55(1):91-101.
著者: G P Buzby, J L Mullen, D C Matthews, C L Hobbs, E F Rosato
雑誌名: Am J Surg. 1980 Jan;139(1):160-7.
Abstract/Text Based on assessment of 161 nonemergency general surgical patients, a multiparameter index of nutritional status was defined relating the risk of postoperative complications to baseline nutritional status. When applied prospectively to 100 gastrointestinal surgical patients, this index provided an accurate, quantitative estimate of operative risk, permitting rational selection of patients to receive preoperative nutritional support.

PMID 7350839  Am J Surg. 1980 Jan;139(1):160-7.
著者: M Laporte, L Villalon, J Thibodeau, H Payette
雑誌名: J Nutr Health Aging. 2001;5(4):292-4.
Abstract/Text This study was conducted to assess the validity and the reliability of simple tools to screen the protein-energy malnutrition (PEM) risk among the elderly population in healthcare facilities. An initial screening tool, made up of nine PEM risk factors, was previously developed to be validated. This tool was quite complex and showed low validity results. A stepwise regression analysis determined significant risk factors (P < or = 0.05) among those included in the initial tool. These were the foundation to develop two simplified screening tools. One included Body Mass Index (BMI) and % weight loss over time. The second included BMI and albumin. Both tools classified subjects in low or high PEM risk levels. In the present study, the simple tools were assessed in a sample of 142 elderly subjects divided into two categories: acute care elderly (ACE, n=72) and long-term care elderly (LTCE, n=70). The simple tools were administered by a dietetic technician and a nurse with the purpose of assessing inter-rater and test-retest reliabilities. The criterion validity of the simple tools were assessed in comparison to in-depth nutritional assessments carried out by a dietitian. The validity results were ranked between 60.5% and 91.7%. The reliability scores showed levels of agreement of 70.8% to 93.1% and kappa coefficients ranking between 0.59(+/-0.07) and 0.79(+/-0.05). Simple tools are now available for efficiently screening the PEM risk among the elderly population on a healthcare facility-wide basis.

PMID 11753498  J Nutr Health Aging. 2001;5(4):292-4.
著者: Lenny M W van Venrooij, Paul A M van Leeuwen, Wendy Hopmans, Mieke M M J Borgmeijer-Hoelen, Rien de Vos, Bas A J M De Mol
雑誌名: J Am Diet Assoc. 2011 Dec;111(12):1924-30. doi: 10.1016/j.jada.2011.09.009.
Abstract/Text The objective of this study was to compare the quick-and-easy undernutrition screening tools, ie, Short Nutritional Assessment Questionnaire and Malnutrition Universal Screening Tool, in patients undergoing cardiac surgery with respect to their accuracy in detecting undernutrition measured by a low-fat free mass index (FFMI; calculated as kg/m(2)), and secondly, to assess their association with postoperative adverse outcomes. Between February 2008 and December 2009, a single-center observational cohort study was performed (n=325). A low FFMI was set at ≤14.6 in women and ≤16.7 in men measured using bioelectrical impedance spectroscopy. To compare the accuracy of the Malnutrition Universal Screening Tool and Short Nutritional Assessment Questionnaire in detecting low FFMI sensitivity, specificity, and other accuracy test characteristics were calculated. The associations between the Malnutrition Universal Screening Tool and Short Nutritional Assessment Questionnaire and adverse outcomes were analyzed using logistic regression analyses with odds ratios and 95% confidence intervals (CI) presented. Sensitivity and receiver operator characteristic-based area under the curve to detect low FFMI were 59% and 19%, and 0.71 (95% CI: 0.60 to 0.82) and 0.56 (95% CI: 0.44 to 0.68) for the Malnutrition Universal Screening Tool and Short Nutritional Assessment Questionnaire, respectively. Accuracy of the Malnutrition Universal Screening Tool improved when age and sex were added to the nutritional screening process (sensitivity 74%, area under the curve: 0.72 [95% CI: 0.62 to 0.82]). This modified version of the Malnutrition Universal Screening Tool, but not the original Malnutrition Universal Screening Tool or Short Nutritional Assessment Questionnaire, was associated with prolonged intensive care unit and hospital stay (odds ratio: 2.1, 95% CI: 1.3 to 3.4; odds ratio: 1.6, 95% CI: 1.0 to 2.7). The accuracy to detect a low FFMI was considerably higher for the Malnutrition Universal Screening Tool than for the Short Nutritional Assessment Questionnaire, although still marginal. Further research to evaluate the modified version of the Malnutrition Universal Screening Tool, ie, the cardiac surgery-specific Malnutrition Universal Screening Tool, is needed prior to implementing.

Copyright © 2011 American Dietetic Association. Published by Elsevier Inc. All rights reserved.
PMID 22117670  J Am Diet Assoc. 2011 Dec;111(12):1924-30. doi: 10.1016・・・
著者: Jane V White, Peggi Guenter, Gordon Jensen, Ainsley Malone, Marsha Schofield, Academy Malnutrition Work Group, A.S.P.E.N. Malnutrition Task Force, A.S.P.E.N. Board of Directors
雑誌名: JPEN J Parenter Enteral Nutr. 2012 May;36(3):275-83. doi: 10.1177/0148607112440285.
Abstract/Text The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommend that a standardized set of diagnostic characteristics be used to identify and document adult malnutrition in routine clinical practice. An etiologically based diagnostic nomenclature that incorporates a current understanding of the role of the inflammatory response on malnutrition's incidence, progression, and resolution is proposed. Universal use of a single set of diagnostic characteristics will facilitate malnutrition's recognition, contribute to more valid estimates of its prevalence and incidence, guide interventions, and influence expected outcomes. This standardized approach will also help to more accurately predict the human and financial burdens and costs associated with malnutrition's prevention and treatment and further ensure the provision of high-quality, cost-effective nutrition care.

PMID 22535923  JPEN J Parenter Enteral Nutr. 2012 May;36(3):275-83. do・・・
著者: Cathy Payne, Philip J Wiffen, Suzanne Martin
雑誌名: Cochrane Database Syst Rev. 2012 Jan 18;1:CD008427. doi: 10.1002/14651858.CD008427.pub2. Epub 2012 Jan 18.
Abstract/Text BACKGROUND: Fatigue and unintentional weight loss are two of the commonest symptoms experienced by people with advanced progressive illness. Appropriate interventions may bring considerable improvements in function and quality of life to seriously ill people and their families, reducing physical, psychological and spiritual distress.
OBJECTIVES: To conduct an overview of the evidence available on the efficacy of interventions used in the management of fatigue and/or unintentional weight loss in adults with advanced progressive illness by reviewing the evidence contained within Cochrane reviews.
METHODS: We searched the Cochrane Database of Systematic Reviews (CDSR) for all systematic reviews evaluating any interventions for the management of fatigue and/or unintentional weight loss in adults with advanced progressive illness (The Cochrane Library 2010, Issue 8). We reviewed titles of interest by abstract. Where the relevance of a review remained unclear we reached a consensus regarding the relevance of the participant group and the outcome measures to the overview. Two overview authors extracted the data independently using a data extraction form. We used the measurement tool AMSTAR (Assessment of Multiple SysTemAtic Reviews) to assess the methodological quality of each systematic review.
MAIN RESULTS: We included 27 systematic reviews (302 studies with 31,833 participants) in the overview. None of the included systematic reviews reported quantitative data on the efficacy of interventions to manage fatigue or weight loss specific to people with advanced progressive illness. All of the included reviews apart from one were deemed of high methodological quality. For the remaining review we were unable to ascertain the methodological quality of the research strategy as it was described. None of the systematic reviews adequately described whether conflict of interests were present within the included studies.Management of fatigue Amyotrophic lateral sclerosis/motor neuron disease (ALS/MND) - we identified one systematic review (two studies and 52 participants); the intervention was exercise.Cancer - we identified five systematic reviews (116 studies with 17,342 participants); the pharmacological interventions were eicosapentaenoic acid (EPA) and any drug therapy for the management of cancer-related fatigue and the non pharmacological interventions were exercise, interventions by breast care nurses and psychosocial interventions.Chronic obstructive pulmonary disease (COPD) - we identified three systematic reviews (59 studies and 4048 participants); the interventions were self management education programmes, nutritional support and pulmonary rehabilitation.Cystic fibrosis - we identified one systematic review (nine studies and 833 participants); the intervention was physical training.Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) - we identified two systematic reviews (21 studies and 748 participants); the interventions were progressive resistive exercise and aerobic exercise.Multiple sclerosis (MS) - we identified five systematic reviews (23 studies and 1502 participants); the pharmacological interventions were amantadine and carnitine. The non pharmacological interventions were diet, exercise and occupational therapy.Mixed conditions in advanced stages of illness - we identified one systematic review (five studies and 453 participants); the intervention was medically assisted hydration.Management of weight loss ALS/MND - we identified one systematic review but no studies met the inclusion criteria for the systematic review; the intervention was enteral tube feeding.Cancer - we identified three systematic reviews with a fourth systematic review also containing extractable data on cancer (66 studies and 5601 participants); the pharmacological interventions were megestrol acetate and eicosapentaenoic acid (EPA) (this systematic review is also included in the cancer fatigue section above). The non pharmacological interventions were enteral tube feeding and non invasive interventions for patients with lung cancer.COPD - we identified one systematic review (59 studies and 4048 participants); the intervention was nutritional support. This systematic review is also included in the COPD fatigue section.Cystic fibrosis - we identified two systematic reviews (three studies and 131 participants); the interventions were enteral tube feeding and oral calorie supplements.HIV/AIDS - we identified four systematic reviews (42 studies and 2071 participants); the pharmacological intervention was anabolic steroids. The non pharmacological interventions were nutritional interventions, progressive resistive exercise and aerobic exercise. Both of the systematic reviews on exercise interventions were also included in the HIV/AIDS fatigue section.MS - we found no systematic reviews which considered interventions to manage unintentional weight loss for people with a clinical diagnosis of multiple sclerosis at any stage of illness.Mixed conditions in advanced stages of illness - we identified two systematic reviews (32 studies and 4826 participants); the interventions were megestrol acetate and medically assisted nutrition.
AUTHORS' CONCLUSIONS: There is a lack of robust evidence for interventions to manage fatigue and/or unintentional weight loss in the advanced stage of progressive illnesses such as advanced cancer, heart failure, lung failure, cystic fibrosis, multiple sclerosis, motor neuron disease, Parkinson's disease, dementia and AIDS. The evidence contained within this overview provides some insight into interventions which may prove of benefit within this population such as exercise, some pharmacological treatments and support for self management.Researchers could improve the methodological quality of future studies by blinding of outcome assessors. Adopting uniform reporting mechanisms for fatigue and weight loss outcome measures would also allow the opportunity for meta-analysis of small studies.Researchers could also improve the applicability of recommendations for interventions to manage fatigue and unintentional weight loss in advanced progressive illness by including subgroup analysis of this population within systematic reviews of applicable interventions.More research is required to ascertain the best interventions to manage fatigue and/or weight loss in advanced illness. There is a need for standardised reporting of these symptoms and agreement amongst researchers of the minimum duration of studies and minimum percentage change in symptom experience that proves the benefits of an intervention. There are, however, challenges in providing meaningful outcome measurements against a background of deteriorating health through disease progression. Interventions to manage these symptoms must also be mindful of the impact on quality of life and should be focused on patient-orientated rather than purely disease-orientated experiences for patients. Systematic reviews and primary intervention studies should include the impact of the interventions on standardised validated quality of life measures.

PMID 22258985  Cochrane Database Syst Rev. 2012 Jan 18;1:CD008427. doi・・・
著者: Ivone M Ferreira, Dina Brooks, John White, Roger Goldstein
雑誌名: Cochrane Database Syst Rev. 2012 Dec 12;12:CD000998. doi: 10.1002/14651858.CD000998.pub3. Epub 2012 Dec 12.
Abstract/Text BACKGROUND: Individuals with chronic obstructive pulmonary disease (COPD) and low body weight have impaired pulmonary status, reduced diaphragmatic mass, lower exercise capacity and higher mortality than those who are adequately nourished. Nutritional support may be useful for their comprehensive care.
OBJECTIVES: To assess the impact of nutritional support on anthropometric measures, pulmonary function, respiratory and peripheral muscles strength, endurance, functional exercise capacity and health-related quality of life (HRQoL) in COPD.If benefit is demonstrated, to perform subgroup analysis to identify treatment regimens and subpopulations that demonstrate the greatest benefits.
SEARCH METHODS: We identified randomised controlled trials (RCTs) from the Cochrane Airways Review Group Trials Register, a handsearch of abstracts presented at international meetings and consultation with experts. Searches are current to April 2012.
SELECTION CRITERIA: Two review authors independently selected trials for inclusion, assessed risk of bias and extracted the data. Decisions were made by consensus.
DATA COLLECTION AND ANALYSIS: We used post-treatment values when pooling the data for all outcomes, and change from baseline scores for primary outcomes. We used mean difference (MD) to pool data from studies that measured outcomes with the same measurement tool and standardised mean difference (SMD) when the outcomes were similar but the measurement tools different. We contacted authors of the primary studies for missing data.We established clinical homogeneity prior to pooling. We presented the results with 95% confidence intervals (CI) in the text and in a 'Summary of findings' table.
MAIN RESULTS: We included 17 studies (632 participants) of at least two weeks of nutritional support. There was moderate-quality evidence (14 RCTs, 512 participants, nourished and undernourished) of no significant difference in final weight between those who received supplementation and those who did not (MD 0.69 kg; 95% CI -0.86 to 2.24). Pooled data from 11 RCTs (325 undernourished patients) found a statistically significant weight gain (MD 1.65 kg; 95% CI 0.14 to 3.16) in favour of supplementation; three RCTs (116 mixed population) found no significant difference between groups (MD -1.28 kg; 95% CI -6.27 to 3.72). However, when analysed as change from baseline, there was significant improvement with supplementation: 14 RCTs (five of which had imputed SE), MD 1.62 kg (95% CI 1.27 to 1.96 ); 11 RCTs (malnourished), MD 1.73 kg (95% CI 1.29 to 2.17) and three RCTs (mixed), MD 1.44 kg (95% CI 0.68 to 2.19).There was low-quality evidence from five RCTs (six comparisons, 287 participants) supporting a significant improvement from baseline for fat-free mass/fat-free mass index (SMD 0.57; 95% CI 0.04 to 1.09), which was larger for undernourished patients (three RCTs, 125 participants; SMD 1.08; 95% CI 0.70 to 1.47). There was no significant change from baseline noted for adequately nourished patients (one RCT, 71 participants; SMD 0.27; 95% CI -0.20 to 0.73), or for a mixed population (two RCTs, 91 participants; SMD -0.05; 95% CI -0.76 to 0.65).There was moderate-quality evidence from two RCTs (91 mixed participants) that nutritional supplementation significantly improved fat mass/fat mass index from baseline (SMD 0.90; 95% CI 0.46 to 1.33).There was low-quality evidence (eight RCTs, 294 participants) of an increase in mid-arm muscle circumference change (MAMC; MD 0.29; 95% CI 0.02 to 0.57).There was low-quality evidence (six RCTs, 125 participants) of no significant difference in change from baseline scores for triceps measures (MD 0.54; 95% CI -0.16 to 1.24).There was low-quality evidence (five RCTs, 142 participants) of no significant difference between groups in the six-minute walk distance (MD 14.05 m; 95% CI -24.75 to 52.84), 12-minute walk distance or in shuttle walking. However, the pooled change from baseline for the six-minute walk distance was significant (MD 39.96 m; 95% CI 22.66 to 57.26).There was low-quality evidence (seven RCTs, 228 participants) that there was no significant difference between groups in the forced expiratory volume in one second (FEV(1); SMD -0.01; 95% CI -0.31 to 0.30) when measured in litres or percentage predicted.There was low-quality evidence (nine RCTs, 245 participants) of no significant between group difference in maximum inspiratory pressure (MIP; MD 3.54 cm H(2)O; 95% CI -0.90 to 7.99), but those who received supplementation had a higher maximum expiratory pressure (MEP; MD 9.55 cm H(2)O; 95% CI 2.43 to 16.68). For malnourished patients (seven RCTs, 189 participants), those with supplementation had significantly better MIP (MD 5.02; 95% CI 0.29 to 9.76) and MEP (MD 12.73; 95% CI 4.91 to 20.55).There was low-quality evidence (four RCTs, 130 participants) of no significant difference in HRQoL total score (SMD -0.36; 95% CI -0.77 to 0.06) when pooling results from both the St George's Respiratory Questionnaire (SGRQ) and the Chronic Respiratory Questionnaire (CRQ).Two trials (67 participants) used the SGRQ to measure individual domains of activity, impact and symptoms. At the end of treatment, the pooled total SGRQ score was both statistically and clinically significant (MD -6.55; 95% CI -11.7 to -1.41). The three RCTs (123 participants) that used the CRQ to measure the change in individual domains (dyspnoea, fatigue, emotion, mastery), found no significant difference between groups.
AUTHORS' CONCLUSIONS: We found moderate-quality evidence that nutritional supplementation promotes significant weight gain among patients with COPD, especially if malnourished. Nourished patients may not respond to the same degree to supplemental feeding. We also found a significant change from baseline in fat-free mass index/fat-free mass, fat mass/fat mass index, MAMC (as a measure of lean body mass), six-minute walk test and a significant improvement in skinfold thickness (as measure of fat mass, end score) for all patients. In addition, there were significant improvements in respiratory muscle strength (MIP and MEP) and overall HRQoL as measured by SGRQ in malnourished patients with COPD.These results differ from previous reviews and should be considered in the management of malnourished patients with COPD.

PMID 23235577  Cochrane Database Syst Rev. 2012 Dec 12;12:CD000998. do・・・
著者: J Kondrup, N Johansen, L M Plum, L Bak, I Højlund Larsen, A Martinsen, J R Andersen, H Baernthsen, E Bunch, N Lauesen
雑誌名: Clin Nutr. 2002 Dec;21(6):461-8.
Abstract/Text BACKGROUND AND AIMS: Many patients in hospitals are undernourished and nutritional care is inadequate in most hospitals. The aim of this investigation was to gain insight into how this situation could be improved.
METHODS: Seven hundred and fifty randomly selected patients were screened at admission in three hospitals and surveyed during their entire hospitalization. Each time a patient was not treated according to a clearly defined nutritional standard, the nurse responsible for the patient was interviewed about possible reasons according to preformed questionnaires.
RESULTS: The investigators found that 22% of the patients were nutritionally at-risk, and that only 25% of these patients received an adequate amount of energy and protein. The departments had only screened for nutritional problems in 60% of the cases. Only 47% of the patients, who the departments judged to be at-risk patients, had a nutrition plan worked out, and only about 30% of the at-risk patients were monitored by the departments by recording of dietary intake and/or body weight. The main causes for inadequate nutritional care were lack of instructions to deal with these problems, and lack of basic knowledge with respect to dietary requirements and practical aspects of the hospital's food provision. Patient-related aspects and the system of food provision also contributed, but only to a small degree.
CONCLUSIONS: These findings form the basis of the strategy to improve nutritional care in these hospitals.

PMID 12468365  Clin Nutr. 2002 Dec;21(6):461-8.
著者: G L Blackburn, B R Bistrian, B S Maini, H T Schlamm, M F Smith
雑誌名: JPEN J Parenter Enteral Nutr. 1977;1(1):11-22.
Abstract/Text
PMID 98649  JPEN J Parenter Enteral Nutr. 1977;1(1):11-22.
著者: S Klein, J Kinney, K Jeejeebhoy, D Alpers, M Hellerstein, M Murray, P Twomey
雑誌名: JPEN J Parenter Enteral Nutr. 1997 May-Jun;21(3):133-56.
Abstract/Text In the last 30 years, marked advances in enteral feeding techniques, venous access, and enteral and parenteral nutrient formulations have made it possible to provide nutrition support to almost all patients. Despite the abundant medical literature and widespread use of nutritional therapy, many areas of nutrition support remain controversial. Therefore, the leadership at the National Institutes of Health, The American Society for Parenteral and Enteral Nutrition, and The American Society for Clinical Nutrition convened an advisory committee to perform a critical review of the current medical literature evaluating the clinical use of nutrition support; the goal was to assess our current body of knowledge and to identify the issues that deserve further investigation. The panel was divided into five groups to evaluate the following areas: nutrition assessment, nutrition support in patients with gastrointestinal diseases, nutrition support in wasting diseases, nutrition support in critically ill patients, and perioperative nutrition support. The findings from each group are summarized in this report. This document is not meant to establish practice guidelines for nutrition support. The use of nutritional therapy requires a careful integration of data from pertinent clinical trials, clinical expertise in the illness or injury being treated, clinical expertise in nutritional therapy, and input from the patient and his/her family.

PMID 9168367  JPEN J Parenter Enteral Nutr. 1997 May-Jun;21(3):133-56・・・
著者: K Rosenbaum, J Wang, R N Pierson, D P Kotler
雑誌名: JPEN J Parenter Enteral Nutr. 2000 Mar-Apr;24(2):52-5.
Abstract/Text OBJECTIVES: To define the limits of change in body weight and body composition after different time intervals in healthy, normal adults.
METHODS: Prospective and retrospective analyses of paired body composition studies in a total of 326 healthy adults, ages 18 to 97. Measurements included body weight, fat and fat-free mass (FFM) by dual x-ray absorptiometry (DXA) and bioimpedance analysis (BIA), plus body cell mass (BCM) by whole-body counting of 40K and BIA.
RESULTS: Time interval between studies was a significant predictor of the differences in paired studies. The 95% confidence intervals for percent difference were lowest for body weight, intermediate for BCM and FFM, and highest for fat, in part because of the differences in sizes of these body compartments. There were significant associations among the changes in body composition by BIA and by criterion methods, suggesting that the observed changes are real.
CONCLUSIONS: The normal variation in body weight and body composition increases over time. Time-dependent criteria may increase the sensitivity in diagnosing malnutrition. Interpreting changes in body compartments requires consideration of the size of each compartment.

PMID 10772182  JPEN J Parenter Enteral Nutr. 2000 Mar-Apr;24(2):52-5.
著者: A KEYS
雑誌名: J Am Med Assoc. 1948 Oct 16;138(7):500-11.
Abstract/Text
PMID 18884888  J Am Med Assoc. 1948 Oct 16;138(7):500-11.
著者: G S Sacks, K Dearman, W H Replogle, V L Cora, M Meeks, T Canada
雑誌名: J Am Coll Nutr. 2000 Oct;19(5):570-7.
Abstract/Text OBJECTIVE: The primary objective of this study was to assess the use of Subjective Global Assessment to identify nutrition-associated complications and death in a geriatric population. A secondary objective was to evaluate the ability of Subjective Global Assessment to identify geriatric residents of long-term care facilities who were undernourished or at risk for developing undernutrition.
METHODS: Fifty-three consecutive residents who were > or = 65 years of age and had been residing in a long-term care facility for < 2 weeks were enrolled in the study. The Subjective Global Assessment Classification technique was performed according to the procedure outlined by Detsky and colleagues. Residents were classified as well-nourished (A), mild/moderately undernourished (B) or severely undernourished (C). In addition, a Subjective Global Assessment Composite Score was derived. Subjective Global Assessment measures were compared with two traditional objective measurements of nutritional status: serum albumin and serum total cholesterol. Outcome measurements of nutrition-associated complications were determined over a 3-month period by recording the incidence of major infections, decubitus ulcers, nutrition-related hospital readmissions, and mortality.
RESULTS: Sixteen residents (30.2%) were categorized as Subjective Global Assessment class A, 28 residents (52.8%) were class B, and 9 residents (17%) were class C. A significant association was found between nutritional status as determined by Subjective Global Assessment Composite Score and nutrition-associated complications (p<0.05). Subjective Global Assessment Classification was related to death (p<0.05) with severely undernourished residents having the highest mortality rate. Hypoalbuminemia only demonstrated a significant relationship with nutrition-associated complications (p<0.05), whereas hypocholesterolemia was associated with death (p<0.05).
CONCLUSIONS: Subjective Global Assessment of nutritional status appears to be a simple, noninvasive and cost-effective tool for assessing nutritional status of geriatric residents in long-term care facilities. This assessment tool is also beneficial for identifying patients with increased risk of nutrition-associated complications as well as death.

PMID 11022870  J Am Coll Nutr. 2000 Oct;19(5):570-7.
著者: Kristina Norman, Nicole Stobäus, M Cristina Gonzalez, Jörg-Dieter Schulzke, Matthias Pirlich
雑誌名: Clin Nutr. 2011 Apr;30(2):135-42. doi: 10.1016/j.clnu.2010.09.010. Epub 2010 Oct 30.
Abstract/Text BACKGROUND & AIMS: Among all muscle function tests, measurement of hand grip strength has gained attention as a simple, non-invasive marker of muscle strength of upper extremities, well suitable for clinical use. This review outlines the prognostic relevance of grip strength in various clinical and epidemiologic settings and investigates its suitability as marker of nutritional status in cross-sectional as well as intervention studies.
METHODS: Studies investigating grip strength as prognostic marker or nutritional parameter in cross-sectional or intervention studies were summarized.
RESULTS AND CONCLUSIONS: Numerous clinical and epidemiological studies have shown the predictive potential of hand grip strength regarding short and long-term mortality and morbidity. In patients, impaired grip strength is an indicator of increased postoperative complications, increased length of hospitalization, higher rehospitalisation rate and decreased physical status. In elderly in particular, loss of grip strength implies loss of independence. Epidemiological studies have moreover demonstrated that low grip strength in healthy adults predicts increased risk of functional limitations and disability in higher age as well as all-cause mortality. As muscle function reacts early to nutritional deprivation, hand grip strength has also become a popular marker of nutritional status and is increasingly being employed as outcome variable in nutritional intervention studies.

Copyright © 2010 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
PMID 21035927  Clin Nutr. 2011 Apr;30(2):135-42. doi: 10.1016/j.clnu.2・・・
著者: M L Omran, J E Morley
雑誌名: Nutrition. 2000 Jan;16(1):50-63.
Abstract/Text Protein-energy malnutrition is a prevalent problem in older persons. Its relation to increased morbidity and mortality has been well documented. Early recognition of malnutrition allows for a timely intervention. A large proportion of chronic diseases affecting older persons can be either prevented or significantly improved by improving nutrition, which underscores the importance of developing a screening system that can trigger a more comprehensive evaluation when indicated. Screening for malnutrition in older persons can be difficult because of the normal age-related changes in many of the commonly used parameters. A comprehensive nutritional evaluation includes a complete history and physical examination in addition to a more specific nutrition-oriented assessment. Specific nutritional assessment includes estimating food intake, anthropometric measurements, and evaluation of several biochemical parameters commonly affected by changes in nutritional status. In this article, we review the commonly used tools for nutritional assessment in older persons. The goal is to promote disease-free, active, and successful aging.

PMID 10674236  Nutrition. 2000 Jan;16(1):50-63.
著者: M Molly McMahon, Erin Nystrom, Carol Braunschweig, John Miles, Charlene Compher, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors, American Society for Parenteral and Enteral Nutrition
雑誌名: JPEN J Parenter Enteral Nutr. 2013 Jan;37(1):23-36. doi: 10.1177/0148607112452001. Epub 2012 Jun 29.
Abstract/Text BACKGROUND: Hyperglycemia is a frequent occurrence in adult hospitalized patients who receive nutrition support. Both hyperglycemia and hypoglycemia (resulting from attempts to correct hyperglycemia) are associated with adverse outcomes in diabetic as well as nondiabetic patients. This American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Guideline summarizes the most current evidence and provides guidelines for the desired blood glucose goal range in hospitalized patients receiving nutrition support, the definition of hypoglycemia, and the rationale for use of diabetes-specific enteral formulas in hospitalized patients.
METHOD: A systematic review of the best available evidence to answer a series of questions regarding glucose control in adults receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the A.S.P.E.N. Board of Directors.
RESULTS/CONCLUSIONS: 1. What is the desired blood glucose goal range in adult hospitalized patients receiving nutrition support? We recommend a target blood glucose goal range of 140-180 mg/dL (7.8-10 mmol/L). (Strong) 2. How is hypoglycemia defined in adult hospitalized patients receiving nutrition support? We recommend that hypoglycemia be defined as a blood glucose concentration of <70 mg/dL (<3.9 mmol/L). (Strong) 3. Should diabetes-specific enteral formulas be used for adult hospitalized patients with hyperglycemia? We cannot make a recommendation at this time.

PMID 22753619  JPEN J Parenter Enteral Nutr. 2013 Jan;37(1):23-36. doi・・・
著者: J A Harris, F G Benedict
雑誌名: Proc Natl Acad Sci U S A. 1918 Dec;4(12):370-3.
Abstract/Text
PMID 16576330  Proc Natl Acad Sci U S A. 1918 Dec;4(12):370-3.
著者: Alfonso J Cruz-Jentoft, Jean Pierre Baeyens, Jürgen M Bauer, Yves Boirie, Tommy Cederholm, Francesco Landi, Finbarr C Martin, Jean-Pierre Michel, Yves Rolland, Stéphane M Schneider, Eva Topinková, Maurits Vandewoude, Mauro Zamboni, European Working Group on Sarcopenia in Older People
雑誌名: Age Ageing. 2010 Jul;39(4):412-23. doi: 10.1093/ageing/afq034. Epub 2010 Apr 13.
Abstract/Text The European Working Group on Sarcopenia in Older People (EWGSOP) developed a practical clinical definition and consensus diagnostic criteria for age-related sarcopenia. EWGSOP included representatives from four participant organisations, i.e. the European Geriatric Medicine Society, the European Society for Clinical Nutrition and Metabolism, the International Association of Gerontology and Geriatrics-European Region and the International Association of Nutrition and Aging. These organisations endorsed the findings in the final document. The group met and addressed the following questions, using the medical literature to build evidence-based answers: (i) What is sarcopenia? (ii) What parameters define sarcopenia? (iii) What variables reflect these parameters, and what measurement tools and cut-off points can be used? (iv) How does sarcopenia relate to cachexia, frailty and sarcopenic obesity? For the diagnosis of sarcopenia, EWGSOP recommends using the presence of both low muscle mass + low muscle function (strength or performance). EWGSOP variously applies these characteristics to further define conceptual stages as 'presarcopenia', 'sarcopenia' and 'severe sarcopenia'. EWGSOP reviewed a wide range of tools that can be used to measure the specific variables of muscle mass, muscle strength and physical performance. Our paper summarises currently available data defining sarcopenia cut-off points by age and gender; suggests an algorithm for sarcopenia case finding in older individuals based on measurements of gait speed, grip strength and muscle mass; and presents a list of suggested primary and secondary outcome domains for research. Once an operational definition of sarcopenia is adopted and included in the mainstream of comprehensive geriatric assessment, the next steps are to define the natural course of sarcopenia and to develop and define effective treatment.

PMID 20392703  Age Ageing. 2010 Jul;39(4):412-23. doi: 10.1093/ageing/・・・
著者: David Allen August, Maureen B Huhmann, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors
雑誌名: JPEN J Parenter Enteral Nutr. 2009 Sep-Oct;33(5):472-500. doi: 10.1177/0148607109341804.
Abstract/Text
PMID 19713551  JPEN J Parenter Enteral Nutr. 2009 Sep-Oct;33(5):472-50・・・

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