Revista Nutricion 41-2

SOCIEDAD CHILENA DE NUTRICINBROMATOLOGA Y TOXICOLOGA

FUNDADA EN 1943

REVISTA CHILENA DE

NUTRICIN

EDITOR Santiago Muzzo B.Facultad de Medicina, U. Diego Portales Telfono: (56-2) 2676 2854 / E-mail: [email protected] EDITORES ASOCIADOS Jaime Rozowski N. Departamento de Nutricin, Diabetes y Metabolismo. Facultad de Medicina, P. U. Catlica Telfono: (56-2) 2686 3859 / Fax: (56-2) 2633 8298 / E-mail: [email protected] Julio Espinoza M. Departamento de Pediatra. Facultad de Medicina, U. de Chile Telfono: (56-2) 2544 6413 / Fax: (56-2) 2556 2437 / E-mail: [email protected] Francisco Mardones S. Departamento de Salud Pblica, P. U. CatlicaTelfono: (56-2) 2354 6898 / Fax: (56-2) 2633 1840 / E-mail: [email protected] Jos Luis Santos M. Departamento de Nutricin, Diabetes y Metabolismo. Facultad de Medicina, P. U. Catlica Telfono: (56-2) 2354 3862 / Fax: (56-2) 2633 8298 / E-mail: [email protected]

DIRECTIVA 2013 - 2014

Presidente Profesor Jos Luis Santos M. Vicepresidente Profesor Francisco Prez B.

Secretario Profesor Oscar Castillo V. Directores Nutr. Vernica Cornejo E. Dra. Sylvia Cruchet M. Nutr. Vilma Quitral R. Past-President Nutr. Isabel Zacaras H.

CONSEJO EDITORIAL

Cecilia Albala B. Lab. de Epidemiologa Nutricional y Gentica. INTA, U. de Chile

Eduardo Atalah S. Departamento de Nutricin, Facultad de Medicina, U. de Chile

Oscar Brunser T. Regional Medical Advisor, Infant Nutrition, Nestl-Chile

Oscar Castillo V. Depto. Nutricin, Diabetes y Metabolismo, Facultad de Medicina, P. U. Catlica de Chile

Marta Colombo C. Hospital Van Buren. Valparaso

Vernica Cornejo E. Lab. de Enfermedades Metablicas. INTA. U. de Chile

Eliana Durn F. Depto. Bromatologa, Nutricin y Diettica, Facultad de Farmacia, U. de Concepcin

Mara Anglica Ganga M. Departamento de Ciencias y Tecnologa de Alimentos, U. de Santiago de Chile

Martn Gotteland M. Lab. de Microbiologa en Alimentos y Prebiticos. INTA, U. de Chile

Sandra Hirsch B. Lab. Envejecimiento y Enfermedades crnicas relacionadas con Nutricin. INTA, U. de Chile

Juan Ilabaca M. Servicio de Salud Metropolitano Sur. Santiago

Daniza Ivanovic M. Lab. de Nutricin y Regulacin Metablica. INTA, U. de Chile

Lydia Lera M. Lab. de Epidemiologa Nutricional y Gentica. INTA, U. de Chile

Mariane Lutz R. Depto. de Ciencias Farmacuticas, Facultad de Farmacia, U. de Valparaso

Alberto Maiz G. Departamento de Nutricin, Facultad de Medicina, P. U. Catlica de Chile

Fernando Monckeberg B. Facultad de Medicina, U. Diego Portales

Manuel Olivares G. Lab. de Micronutrientes. INTA, U. de Chile

Javier Parada S. Instituto de Ciencia y Tecnologa de los Alimentos (ICYTAL), U. Austral de Chile

Franco Pedreschi P. Depto. Ingeniera Qumica y Bioprocesos, Escuela de Ingeniera, P. U. Catlica de Chile

Manuel Ruz O. Departamento de Nutricin, Facultad de Medicina, U. de Chile

Judith Salinas C. Unidad de Nutricin Pblica. INTA, U. de Chile

Hernn Speisky C. Lab. de Micronutrientes. INTA, U. de Chile

Ricardo Uauy D. Lab. de Epidemiologa Nutricional y Gentica. INTA, U. de Chile

Alfonso Valenzuela B. Lab. de Lpidos y Antioxidantes. INTA, U. de Chile

Luis Villarroel del P. Departamento de Salud Pblica, Facultad de Medicina, P. U. Catlica de Chile

Fernando Vio del R. Lab. de Epidemiologa Nutricional y Gentica. INTA, U. de Chile

EDITORES REGIONALES

Espaa: Angel Gil H. Depto. Bioqumica y Biologa Molecular, Facultad Farmacia, U. de Granada.

Argentina: Carlos Gonzlez I. Hospital de Clnicas, Buenos Aires.

Per: Nelly Zavaleta Instituto de Investigacin Nutricional, La Molina, Lima.

Paraguay: Laura Mendoza Depto. Nutricin, Hospital Central. Inst. Previsin Social. U. Catlica, Asuncin.

Bolivia: Armando Prez-Cueto E. Asoc. Promocin Inv. y Accin Social. La Paz.

Uruguay: Nora Guigoux Ministerio de Salud y COMEPA, Paysand.

La Revista Chilena de Nutricin es el rgano ofi cial de la Sociedad Chilena de Nutricin, Bro-matologa y Toxicologa. Se publica 4 veces al ao en Marzo, Junio, Septiembre y Diciembre. Sus ofi cinas se encuentran en La Concepcin 81, Ofi cina 1307, Santiago, Chile. Fono-fax 236 9128, e-mail: [email protected]. Toda correspondencia relacionada con subscripciones, cambio de direccin, rdenes para apartados u otras debe ser dirigida a esta direccin. Los manuscritos enviados a publicacin deben ceirse a la Gua para los Autores publicada en cada nmero.

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REVISTA CHILENA DE NUTRICIN

Es editada como rgano ofi cial de la Sociedad Chilena de Nutricin, Bromatologa y Toxi-cologa para la difusin de los conocimientos en el campo de la nutricin y ciencias afi nes. Sus objetivos bsicos son:

1. Ser el rgano de expresin de la investigacin en nutricin y ciencias afi nes realizadas a nivel nacional e internacional.

2. Estimular la investigacin cientfi ca en estas reas proporcionando un medio de difusin para plantear y discutir temas propios de ellas, como asimismo facilitar el intercambio de informacin entre los distintos grupos de investigadores.

3. Ser un rgano de divulgacin de las actividades nacionales e internacionales relacio-nadas con nutricin.

4. Incentivar la especializacin y capacitacin profesional en Alimentacin y Nutricin de acuerdo a los avances cientfi cos y tecnolgicos. En sus pginas se acogen manuscritos en castellano e ingls y en cualquiera de las siguientes categoras: a) Trabajos de ac-tualizacin; b) Trabajos de investigacin (originales) c) Trabajos de Nutricin Aplicada; d) Cartas al Editor: e) Normas Tcnicas; f) Casos Clnicos.

Los manuscritos (3 copias tamao carta, doble espacio) o un CD o envo por correo electrnico al Editor deben enviarse a:

Dr. Santiago Muzzo Editor, Revista Chilena de Nutricin Facultad de Medicina Universidad Diego Portales Ejrcito 233, Piso 1, Santiago CHILE E-mail: [email protected]

Los autores deben atenerse al estilo de la Revista. La Gua para los Autores se encuentra

al fi nal de cada ejemplar.

Las ideas, opiniones y conclusiones expresadas en los artculos son responsabilidad exclusiva de los autores.

La revista tiene inters en establecer intercambio con otras instituciones en relacin a publicaciones, especialmente en el rea de la nutricin y ciencias afi nes.

Representante Legal: Dr. Santiago Muzzo

NDICE / CONTENTS

ARTCULOS ORIGINALES / ORIGINAL ARTICLES126 Las comparaciones entre las ecuaciones de prediccin de la tasa metablica en reposo y la calorimetra indirecta en los adolescentes obesos.

Comparisons between predictive equations of resting metabolic rate and indirect calorimetry in obese teenagers. Bruno A. P. de Oliveira, Carolina F. Nicoletti, Camila B. Gardim, Vitor L. de Andrade, Ismael F. Freitas Jnior.

131 Consejera nutricional incrementa el consumo de alimentos ricos en calcio, pero la ingesta se mantiene por debajo del requierimiento diario. Nutritional counseling increases consumption of calcium-rich foods, but mean intake remains below the daily requirement. Sheila Cerezo de R., Israel Ros C., Alex Brito O., Daniel Lpez de R., Manuel Olivares G., Fernando Pizarro A.

139 Caractersticas clnicas y de laboratorio en pacientes cirrticos asociada con desnutricin moderada o severa. Clinical and laboratory characteristics of cirrhotic patients associated with moderate and severe malnutrition. Samantha Thifani Alrutz Barcelos, Esther Buzaglo Dantas-Corra, Maria Luiza Aires Alencar, Leonardo de Lucca Schiavon, Janaina Luz Narciso-Schiavon.

149 Variables que afectan la satisfaccin con la alimentacin segn nivel socioeconmico: un estudio exploratorio en el sur de Chile. Variables affecting food satisfaction according to socioeconomic status: an exploratory study in southern Chile. Berta Schnettler M., Horacio Miranda V., Ligia Orellana C., Jos Seplveda M., Marc os Mora G., Germn Lobos A.

156 Estrategias efectivas para incrementar el consumo de la bebida lctea "Purita Mam" en gestantes y nodrizas de la provincia de uble, ao 2012. Effective strategies to increasing the consumption of the dairy drink Purita Mam for pregnant and lacting women from the uble province, year 2012. Gloria Snchez S., Carolina Leyton P., Alex Medina G.

161 Contenido de sodio en pan elaborado en panadera de distribucin nacional y comparado con una panadera local en Chilln. Comparison of sodium content in bread from a bakery with national distribution and a local bakery in Chilln. Ximena Aguilera P., Camila Lpez S., Alejandra Rodriguez F., Ximena Sanhueza R., Eduardo Atalah S., Julio Parra F.

167 Aprendizaje basado en problemas (ABP) como estrategia para adquisicin de competencias genricas: estudiantes de nutricin y diettica, Universidad de la Frontera. Problem-based Learning as a strategy for acquisition of generic skills: students of nutrition and dietetics, Universidad de la Frontera. Eugenia Saavedra R., Mnica Illesca P., Mirtha Cabezas G.

ARTCULOS DE ACTUALIZACIN / REVIEW ARTICLES173 Desnutricin infantil y dao del capital humano. Infant undernutrition: Damage to the human capital. Fernando Mnckeberg B.

181 Prevencin del dao: Impacto econmico y social. Damage prevention: Socioeconomic impact. Fernando Mnckeberg B.

191 Residuos de antibiticos en la leche comercializada en Brasil: una revisin de los estudios publicados en los ltimos aos. Antibiotic residues in Brazilian milk: a review of studies published in recent years. Felipe M. Trombete, Regiane R. dos Santos, Andr L. R. Souza

198 Alimentos funcionales, nutracuticos y foshu: vamos hacia un nuevo concepto de alimentacin?. Functional foods, nutraceuticals and foshu: Are we going to a novel food concept?. Alfonso Valenzuela B., Rodrigo Valenzuela B., Julio Sanhueza C., Gladys Morales I.

205 Acidos grasos omega-3 en la nutricin cmo aportarlos?. Omega-3 fatty acids in nutrition, how to get them?. Alfonso Valenzuela B., Rodrigo Valenzuela B.

212 ANUNCIOS / ANNOUNCEMENTES

213 GUA PARA LOS AUTORES / GUIDELINES FOR AUTHORS

Rev Chil Nutr Vol. 41, N2, Junio 2014

126

ARTCULOS ORIGINALES

Las comparaciones entre las ecuaciones deprediccin de la tasa metablica en reposo y lacalorimetra indirecta en los adolescentes obesos

Comparisons between predictive equationsof resting metabolic rate and indirectcalorimetry in obese teenagers


Bruno A P de Oliveira (1)Carolina F Nicoletti (1)

Camila B Gardim (2)Vitor L de Andrade (3)

Ismael F Freitas Jnior (4)

(1) Department of Internal Medicine,Faculdade de Medicina de Ribeiro Preto /Universidade de So Paulo. Brasil. (2) Department of Physiotherapy, Universidade Estadual de Sao Paulo. Brasil.

(3) Department of Rehabilitation and Functional Performance,Faculdade de Medicina de Ribeiro Preto/Universidade de So Paulo. Brasil.

(4) Department of Physical Education, Universidade Estadual de Sao Paulo. Brasil.

Corresponding author: Professor

Bruno Affonso Parenti de OliveiraClinical Nutrition- Department of Internal Medicine

Faculty of Medicine of Ribeirao Preto, University of So PauloRibeiro Preto - SP, Brazil. Avenida dos Bandeirantes, 3900. Ribeirao Preto, SP,

Brazil, Zip code: 14049-900Phone: 55 16 36024810.

E-mail: [email protected]

Este trabajo fue recibido el 24 de Febrero de 2014y aceptado para ser publicado el 19 de Mayo de 2014.

ABSTRACTObjective: To measure the accuracy of predictive equations of resting metabolic rate (RMR) in obese teenagers in relation to indirect calorimetry (IC). Methods: This study was conducted with 116 obese teenagers (60 males; 13.71.1 years). The RMR was calculated from Harris and Benedict, Schofi eld, WHO, Henry and Rees equations. The RMR was measured by the QUARK-RMR system. The comparison between predictive equations and IC was by the Students t test. The reliability of data between predictive equations and IC was verifi ed by the typical error of measu-rement (TEM) and the coeffi cient of variation (CV%). Results: Henrys equation was signifi cantly different from IC (p

127

Las comparaciones entre las ecuaciones de prediccin de la tasa metablica en reposo y la calorimetra indirecta en los adolescentes obesos

being considered a procedure of high precision and sharpness (12). However, IC is a high-cost, sophisticated technique that requires technical maintenance and a proper environment of use, which can not be used under unfi tting circumstances. Therefore, some predictive equations were developed to estimate peoples RMR according to their gender, age and body mass (13-15).

Those equations were developed and tested in North American and European citizens and may not be fi t for indi-viduals living in different environments such as tropical areas (13-169. Research shows the limitations in the usage of the main predictive equations suggested for international use (17,18) due to factors of gender, maturation, age, climate and body composition which interfere with the resting energy expenditure (REE) (19). Authors point out that the RMR prediction is accepted within a coeffi cient of variation (CV%) from 5 to 10% from the IC measurement (8,9).

Therefore, the use of predictive formulas to estimate the RMR of obese teenagers must be carefully examined while taking into account all the characteristics of the population. The objective of this research was to measured the accuracy of different RMR predictive equations in obese teenagers and comparing the results to the values measured by IC and between the sexes.

SUBJECTS AND METHODS Subjects

To develop this research, 116 obese teenagers (60 males and 56 females) have been measured according to Cole et al. classifi cation (20), residing in Presidente Prudente, So Paulo, Brazil, aged 12 to 16 (13.71.1 years). The volunteers were properly informed of the procedures and objectives of this research, and after agreeing with the requirements, since they are underage, their parents or legal guardians signed a term of consent. This research was approved by the Comit de tica em Pesquisa da Universidade Estadual Paulista Jlio de Mesquita Filho. Protocol n 07/2009.

Anthropometric measuresThe total body mass was measured by an electronic plat-

form Filizola scale, with 0.1 kg precision and 150 kg maximum capacity. A Sanny stadiometer with 0.1 cm precision and 2.20 m maximum extension was used to measure the height (21).

Based on the body mass and height measurements, the Body Mass Index (BMI) was calculated using the following formula: individuals body mass (kilograms), divided by square height (meters), hence the values are accounted in kg/m2.

Resting Metabolic Rate through indirect calorimetryThe RMR was defi ned by the measurement of oxygen

consumption (O2) and carbon dioxide production (CO2) using the QUARK-RMR (COSMED, Rome, Italy) device. The device was calibrated with concentrations of known gases (17% O2 e 5% CO2) according to the manufacturer specifi cations. The RMR was gathered under fi tting conditions: in a quiet room, temperature from 21 to 24C, low lightning and no noises. The oxygen consumption (VO2) and carbon dioxide produc-tion (VCO2) have been measured for 30 minutes, and that the fi rst fi ve minutes were discarded until the individual reaches steady state while the volunteer remained in supine position, awakeduring all the evaluation. The teenagers were previously advised to fast for six hours before the data gathering as well as to not practice any physical activities one day before the exam. Weirs equation (22): [(3.941xVO2) + (1.106xVCO2)] x 1440 was adopted to calculate the human energy requirements of individuals at rest (kcal/day).

Predictive EquationsThe following RMR predictive formulas recommended

and used in teenager research were used (table 1).

Statistical analysisDescriptive statistics were used and the values were

accounted in average and standard deviation (SD). The Kolmogorov-Smirnov test was used to measure the normality of data. Students t test was used to compare male and female independent data. The comparison between predictive equa-tions and IC was carried out by Students t test for dependent samples. CV% between measurements was used to assert data reliability between the predictive equations and IC and typical error of measurement (TEM), established by Hopink (23), was used to measure in absolute values the variation of CI regarding the prediction equations. The statistical signifi cance was established in p

128

P de Oliveira B. y cols.

RESULTSThe anthropometric and energy expenditure variables

are described in table 2. Differences statistically signifi cant between body mass (85.419.4 versus 77.913.3, p

129

in table 3 and no statistically signifi cant differences between them have been found. In literature, Van Mil et al (26), have found that WHOs equation overestimated the human energy expenditure of obese males. Another research published by Schneider e Meyer (12), using Henry and Rees equation, has also verifi ed that the result overestimated the human energy expenditure of males, aging from 12 to 17.

Regarding females, only Henrys equation has showed differences statistically signifi cant when compared to IC (p < 0.02), underestimating the teenagers RMR. Rodrigues et al (27) have showed that Schofi elds equation superestimates 10.5% of energy expenditure when applied to females. On the other hand, Tverskaya et al (28) have verifi ed through the same formula of Schofi elds that the results found in obese females aging from 11 to 18 underestimated IC. These results can be explained due to the fact that the predictive equations were not intended for groups of obese teenagers, but for physically active youngsters and adults (16). Thus, it is important to be careful when applying RMR predictive equations, since the results can be different from one population to another.

According to various authors (12,26) male individuals show higher RMR when compared to females, this is due to the fact that males possess more lean body mass (LBM) than females, since it is key to metabolic expenditure because it is a tissue which is more metabolically active. According to Trevisan and Burini (29) for each kilogram of LBM there is a TEE increase of 50 kcal/day, while the maintenance of muscle mass can help avoid the RMR drop, support the maintenance of body weight and prevent visceral adiposity.

Our results match with the aforementioned, in which the males RMR was higher than the females, therefore, gender is an important factor to be considered in the RMR results. The same can be noted in a research published by Tverskaya et al28, which reports that the gender explains 84% of variation in the RMR of teenagers.

When the genders were analyzed separately, the results of this research were superior for males in relation to other literary articles. This can be verifi ed by Schneider & Meyer (11) who measured 35 overweight and obese males, aging from 12 to 17, where an energy expenditure of 1.900 Kcal/day was reported. For the RMR measured by IC in females the values found were higher, varying from the result reported by Fonseca et al (31) who have assessed 51 female teenagers aging from 10 to 17 and the energy expenditure found was 1.292 Kcal/day.

The CV% was low for each equation in regards to IC, however, when analyzed the absolute values of each prediction equation through TEM and compared with the IC was verifi ed statistics differences (table 3) the IC compared to all equations regardless of gender showed a minimum variation of 339.4 kcal/d to 400 kcal/d.

In conclusion the TEM was considered high in absolu-tevalues that can cause errors when estimating the RMR. Therefore, it is important that specifi c predictive equations are developed for Brazilian obese teenagers.

RESUMENObjetivo: Medir la precisin de las ecuaciones predictivas

de la tasa metablica de reposo (TMR) en los adolescentes obesos en relacin con la calorimetra indirecta (CI). Mtodos: El estudio se realiz en 116 adolescentes obesos (60 nios, 13,7 1,1 aos). La TMR se calcul a partir de las ecuaciones predictivas de Harris y Benedict, Schofi eld, OMS, Henry y Rees. La TMR se midi por el sistema de QUARK-TMR. La comparacin entre las ecuaciones de prediccin y IC se realiz

mediante el test t de Student. La fi abilidad de los datos entre IC y ecuaciones de prediccin fue verifi cada por el error tpico de la medicin (TEM) y el coefi ciente de variacin (CV%). Re-sultados: La ecuacin de Henry fue signifi cativamente diferente de IC (p

130

14. Henry CJK, Rees DG. New predictive equations for the estimation of basal metabolic rate in tropical peoples. Eur J Clin Nutr. 1991;45(4):177-85.

15. FAO/WHO/UNU. Energy and protein requirements. Report of a joint FAO/WHO/UNU Expert Consultation. World Health Organ Tech Rep Ser. 1985;724:1-206.

16. Schofi eld WN. Predicting basal metabolic rate, new stan-dards and review of previous work. Hum Nutr Clin Nutr. 1995;39:5-41.

17. Cruz CM, Silva AF, Anjos LA. A taxa metablica basal superestimada pelas equaes preditivas em universitrias do Rio de Janeiro, Brasil. Arch Latinoam Nutr. 1999; 49 (3):232-7.

18. Wahrlich V, Anjos LA. Validao de equaes de predio da taxa metablica basal em mulheres residentes em Porto Alegre, RS, Brasil. Rev Sade Pblica 2001;35(1):39-45.

19. Fonseca PHS, Duarte MFS. Equaes que estimam a taxa metablica de repouso em adolescentes: histria e validade. Rev Bras Cineantropom Desempenho Hum 2008; 10(4):405-11.

20. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard defi nition for child overweight and obesity worldwide: international survey. BMJ 2000;320:1240-43.

21. Lohman TG, Roche AF, Martorell R. Anthropometric Stan-dardization Reference Manual. Champaign, Illinois: Human Kinetics. 1988; p 177.

22. Weir JB. New methods for calculating metabolic rate with special reference to protein metabolism. J Physiol. 1949;1-9.

23. Hopkins WG. Measures of Reliability in Sports Medicine and Science. Sports Med. 2000;30(1):1-15.

24. Benedetti FJ, Bosa VL, Mocelin HT, Paludo J, Mello ED, Fischer GB. Gasto energtico em adolescentes asmticos com excesso de peso: calorimetria indireta e equaes de predio. Rev Nutr. 2011;24(1):31-40.

25. Chan DFY, Lin AM, Chan MHM, So HK, Chan IHS, Yin AT, et al. Validation of prediction equations for estimating resting energy expenditure in obese Chinese children. J Clin Nutr. 2009;18(2):251-256.

26. Van Mil EG, Westertep KR, Kester ADM, Saris WHM. Energy metabolism in relation to body composition and gender in adolescents. Arch Dis Child. 2001;85:73-8.

27. Rodrigues AE, Marostegan PF, Mancini MC, Dalcanele L, Melo ME, Cercato C, et al. Anlise da taxa metablica de repouso avaliada por calorimetria indireta em mulheres obesas com baixa e alta ingesto calrica. Arq Bras Endo-crinol Metab 2008;52(1):76-84.

28. Tverskaya R, Rising R, Brown D, Lifshitz F. Comparison of several equations an derivation of a new equation for calculating basal metabolic rate in obese children. J Am Coll Nutr. 1998;17(4):333-6.

29. Trevisan MC, Burini RC. Metabolismo de repouso de mulheres ps-menopausadas submetidas a programa de treinamento com pesos (hipertrofi a). Rev Bras Med Esporte 2007;13(2)133-7.

30. Fonseca PHS, Duarte MFS, Barbetta PA. Validation of the equations that estimate the resting metabolic rate in ado-lescent girls. Arq Bras Endocrinol Metab. 2010;54(1):30-6.

P de Oliveira B. y cols.

131

INTRODUCCINEl calcio es un mineral esencial que participa en la regula-

cin de diversos procesos metablicos, especialmente a nivel seo y neuromuscular (1,2). Este micronutriente juega un rol crucial en el desarrollo de huesos y dientes, en la conduccin nerviosa, contraccin muscular, ritmos cardacos, funcin cardiovascular, entre otros (1,3).

La ingesta dietaria de calcio es importante para mantener la salud sea (4). La infancia y la adolescencia son los perodos de la vida ms crticos para alcanzar la masa sea mxima durante la edad adulta (5). La mujer empieza a perder masa sea a partir de los 40 aos, debido al proceso de resorcin del hueso y a la carencia de estrgeno despus de la menopausia,


Consejera nutricional incrementael consumo de alimentos ricos en calcio,pero la ingesta se mantiene por debajodel requierimiento diario

Nutritional counseling increasesconsumption of calcium-rich foods,but mean intake remains belowthe daily requirement

Sheila Cerezo de Ros (1,2,)Israel Ros-Castillo (1,3)

Alex Brito O. (4)Daniel Lpez de Romaa (4,5)

Manuel Olivares G. (4,)Fernando Pizarro A. (4.)

(1) Programa de Magster en Nutricin y Alimentos. Instituto de Nutricin yTecnologa de los Alimentos (INTA), Universidad de Chile. Santiago, Chile.

(2) Departamento de Nutricin, Caja de Seguro Social, Policlnica Santiago Barraza, La Chorrera, Panam.

(3) Fundacin para la Investigacin Nutricional y Desarrollo Integral Oportuno, Ciudad de Panam, Panam.

(4) Laboratorio de Micronutrientes, Instituto de Nutricin y Tecnologade los Alimentos (INTA), Universidad de Chile. Santiago, Chile.

(5) Micronutrient Initiative, Ottawa, Ontario, Canad.

Dirigir la correspondencia a: Nutricionista

Sheila Cerezo de RosCaja de Seguro Social

Policlnica Santiago BarrazaCaja de Seguro Social, La Chorrera, Panam. Telfonos: +507 253-3270, +507 69210271

E-mail: [email protected]

Este trabajo fue recibido el 14 de Febrero de 2014y aceptado para ser publicado el 19 de Mayo de 2014.

ABSTRACTCalcium (Ca) plays a crucial role in the regulation of metabolic processes, especially neuromuscular function and bone health. In Chile, calcium intake in women of childbearing age does not meet the dietary requirement. Objective: To determine whether standard and virtual nutritional counseling increases the dietary calcium intake in Chilean women of childbearing age. Subjects and Methods: Dietary calcium intake in 20 women (mean age 39 5 years) before and after a nutritional education intervention was compared. Nutritional counseling was provided to pro-mote daily consumption of calcium-rich foods. Subsequently, a virtual space was provided to enhance standard counseling. On days 1, 30 and 62 a semi-quantitative food frequency questionnaire was completed by the women. Calcium intake signifi cantly increased post intervention (ANOVA F = 4.43, P= 0.02). Dietary calcium intake was 308 116mg/d at baseline, 354 138mg/d at 30 days, and 412 188mg/d after 62 days. Post intervention, 95% of the participants did not meet the daily intake requirement for calcium; the average percent of adequate intake of calcium was 68 19%. Conclusion: Nutri-tional counseling increased dietary calcium intake in women of reproductive age, but the increase was not enough to meet the daily calcium requirements.Key words: Calcium, micronutrients, dietary intake, nutritional requirements, nutritional counseling.

aumentando el riesgo de osteoporosis (6,7). Datos de la Or-ganizacin Mundial de la Salud indican que la osteoporosis es ms frecuente en las mujeres; afecta a ms de 75 millones de personas en los Estados Unidos de Amrica, Europa y Japn; y es la causa de 8,9 millones de fracturas anualmente en el mundo de las cuales 4,5 millones ocurren en las Amricas y en Europa (8).

El Requerimiento Promedio Estimado (EAR, por sus siglas en ingls) de calcio es de 1000 mg/da para adultos jvenes y mujeres en edad frtil (3). Sin embargo, se ha demostrado que el consumo de calcio en la regin latinoamericana se encuentra por debajo de los requerimientos para la mayora de los grupos etarios (912). En este sentido, la consejera

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nutricional ha demostrado aumentar el consumo de alimentos con alto contenido de este mineral (13,14). Se ha reportado que intervenciones nutricionales por medio de herramientas virtuales han sido efectivas en promover la modifi cacin de conductas alimentarias (1517).

El ao 2011 se llev a cabo un estudio experimental para determinar el efecto de la administracin oral de calcio sobre la absorcin de hierro en mujeres chilenas en edad frtil (18). El siguiente anlisis corresponde a un objetivo secundario pre-defi nido de evaluacin del efecto de la consejera nutricional presencial y virtual en la promocin de la ingesta dietaria de calcio en mujeres participantes en dicho estudio.

SUJETOS Y MTODOSEstudio con diseo antes y despus de una intervencin

de educacin alimentaria y nutricional en 28 mujeres chilenas cuya edad media era 39 5 aos. Las mujeres fueron reclu-tadas de la comuna de Macul y La Florida del Sur Oriente de Santiago de Chile, un rea de nivel socioeconmico bajo. El muestreo fue por conveniencia y utilizando la metodologa en cadena, conocida como muestreo de bola de nieve. El estudio se realiz en el Laboratorio de Micronutrientes del Instituto de Nutricin y Tecnologa de los Alimentos (INTA) de la Universidad de Chile entre Marzo y Julio del ao 2011.

Criterios de exclusin: Mujeres con enfermedad apa-rente, excepto anemia; tabaquismo; embarazo e inters por embarazarse; lactancia; y consumo de micronutrientes en suplementos.

Consideraciones ticas: El presente estudio forma parte del Proyecto FONDECYT 1095038. El estudio fue aprobado por parte del Comit de tica para Estudios en Humanos del Instituto de Nutricin y Tecnologa de los Alimentos (INTA) de la Universidad de Chile. Antes del inicio del estudio se orient

a todas las participantes sobre los benefi cios y posibles riesgos de participar en este estudio, as como tambin se obtuvo su consentimiento informado fi rmado.

Diseo de la intervencin: En el da 1 se realiz una con-sejera nutricional presencial en grupo, la cual fue dirigida por un nutricionista investigador. El objetivo de la consejera fue informar a las participantes sobre los benefi cios del consumo de alimentos fuentes de calcio y los efectos adversos de una baja ingesta dietaria de este mineral. Para la consejera nu-tricional se utiliz una presentacin en multimedia, teniendo una duracin de 45 minutos y se permiti un perodo de 30 minutos adicionales para preguntas y respuestas. En esta primera etapa, tambin se aplic un cuestionario validado de Frecuencia de Consumo Semi Cuantitativo (CFCSC) resumido del ltimo mes (19,20) para determinar la ingesta basal de calcio. Adicionalmente, se estim la ingesta de macronu-trientes y de algunos micronutrientes, con la fi nalidad de detectar potenciales cambios en la adecuacin dietaria ajenos a la modifi cacin de adecuacin dietaria especfi ca de calcio.

Posteriormente, desde el mismo da 1, las participantes tuvieron acceso a un espacio virtual desarrollado a travs de una aplicacin Web2.0 disponible para redes sociales en donde se reforzaba la importancia de la ingesta de calcio dietario a travs de consejera nutricional virtual. Adems, se hizo un seguimiento de preguntas y respuestas relacionadas con el estudio. El acceso a este espacio virtual estuvo disponible para ser visto desde cualquier ordenador, ya sea en casa o en cualquier otra instalacin o equipo que contara con acceso a internet. El seguimiento fue de dos meses, completndose nuevamente el CFCSC los das 30 y 62, habilitndose una encuesta virtual utilizando una aplicacin de Google Drive. La encuesta virtual poda ser contestada desde los ordenadores dispuestos en el Instituto o a travs de ordenadores en casa

FIGURA 1

Algoritmo para la cuantifi cacin de ingesta diaria de macro y micronutrientes.

Adaptado de Pakseresht M, Sharma S, Cao X, Harris R, Caberto C, Wilkens LR, Hennis AJ, Wu SY, Nemesure B, Leske MC. Validation of a quantitative FFQ for the Barbados National Cancer Study. Public Health Nutr 2010;14:426-34.

Cerezo de Ros S. y cols.

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u otro centro de informtica accesible. Cuando la participante reportaba no tener acceso a internet, se citaba al Instituto para realizar la entrevista cara a cara con un nutricionista investigador.

Coleccin de los datos: El CFCSC del da 1 constaba de 27 secciones para evaluar la ingesta usual de alimentos y bebidas en los ltimos 30 das, permitiendo registrar la frecuencia de consumo de alimentos especfi cos ya sea diaria, semanal, quincenal o mensual. El CFCSC constaba de ocho categoras de eleccin para frecuencia, desde nunca hasta 2 veces al da (fi gura 1). Los tamaos de las porciones fueron estima-das utilizando tamaos estandarizados de medidas caseras de Chile, segn Gattas y Aguayo 1977 (21). La ingesta de macronutrientes y minerales se calcul utilizando la Tabla de Composicin Qumica de Alimentos de Chile (22).

La ingesta diaria de alimento fue determinada para cada sujeto. Las categoras de frecuencia de consumo en el CFCSC fueron convertidas a frecuencia mensual. La ingesta diaria de cada alimento en gramos fue obtenida dividiendo la ingesta mensual por 30,4 das (fi gura 1), segn el mtodo descrito por Pakseresh y col 2010 (20). La cantidad de macronutrientes y minerales para cada alimento ingerido, en sus respectivas unidades de medidas, fue obtenida multiplicando la cantidad en gramos ingerida por la cantidad de cada nutriente en 100 g segn la Tabla de Composicin Qumica de Alimentos de Chile (22). La ingesta total se obtuvo sumando la ingesta de cada nutriente por alimento evaluado. Se decidi analizar slo la ingesta de macronutrientes (protenas, carbohidratos y grasas) y de macro minerales (calcio, hierro, fsforo y sodio) debido a que podran variar ante un cambio en el patrn de alimentacin. Se omiten del anlisis las vitaminas y elemen-tos trazas en vista de que su requerimiento se cuantifi can en unidades menores y representaran una difi cultad para medir los cambios en la ingesta. Adems de calcio se decidi medir otros macro minerales para estimar que no existiesen cambios ajenos a la intervencin. Para la clasifi cacin del porcentaje de

adecuacin de minerales se utiliz la referencia del Instituto de Medicina de los Estados Unidos (3), considerando adecuado un rango entre 90 y 110%.

Indicadores antropomtricos: El peso y la talla se midie-ron en el da 1 y el da 62 de la intervencin a travs de una balanza electrnica de precisin Hispana SECA (Model 700, Seca Mechanical Column Scales, Seca Corporation, Germany) con estadimetro incluido y con una sensibilidad de 0,1 kg y 0,1 cm, respectivamente. Para las mediciones antropom-tricas se tomaron tres lecturas y se promediaron los valores. Las participantes vistieron ropa ligera, no utilizaron calzado y mantuvieron la posicin horizontal de Frankfurt. Con el peso y la talla se obtuvo el ndice de Masa Corporal (IMC), variable derivada de la relacin entre el peso en kilogramos sobre la talla en metros al cuadrado (Kg/m2).

Anlisis estadstico: El promedio desviacin estndar (DE) fue utilizado para presentar los datos continuos y frecuen-cia (porcentaje %) para las variables categricas. Un anlisis de varianza de medidas repetidas (ANOVA) con una prueba de contraste de Bonferroni fue utilizado para determinar el cambio en la ingesta dietaria entre los tres CFCSC. Para com-parar las caractersticas antropomtricas al inicio y despus de dos meses, se utiliz la prueba t de Student para medidas repetidas. Todos los anlisis estadsticos fueron realizados con el programa STATA 11,0 (Stata Corp LP, College Station, Texas, USA). Se estableci la signifi cancia estadstica cuando el valor p de las pruebas fue menor de 0,05.

RESULTADOSSe incluyeron en el protocolo inicial 28 mujeres (fi gura 2),

fi nalizando el estudio 20 participantes. El motivo por el cual 8 participantes no completaron el estudio por no realizar las CFCSC en los das 30 y 62, principalmente por falta de acceso a la aplicacin de internet, por no tener conexin a internet, no contar con un equipo computacional o por no contar con el conocimiento necesario para usar un computador, por no

FIGURA 2

Diagrama de fl ujo de los procesos a travs de las fases del estudio.

Consejera nutricional incrementa el consumo de alimentos ricos en calcio, pero la ingesta se mantiene por debajo del requierimiento diario

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ser posible la entrevista cara a cara, o por desercin. Slo se incluyeron en el anlisis fi nal las 20 participantes que com-pletaron todas las evaluaciones.

En cuanto a las caractersticas de las participantes, la edad promedio fue 39,3 4,5 aos. La talla promedio fue 1,56 0,07 m. Luego de tres meses de intervencin, no hubo cambios signifi cativos en las medidas antropomtricas de las participantes; el peso promedio inicial y fi nal fue 62,3 6,7 y 62,6 6,7 kg, respectivamente (p=0,84). El IMC promedio inicial y fi nal fue 25,7 3,2 y 25,8 3,0 kg/m2, respectiva-mente (p=0,89) (tabla 1).

La estimacin de ingesta dietaria diaria de calcio aument progresivamente despus de dos meses de consejera virtual y presencial (ANOVA, medidas repetidas; F=4,43; p=0,02). La ingesta dietaria de calcio en el perodo basal fue de 308 116 mg/d, al da 30 fue 354 138 mg/d y al da 62 fue 412 188 (tabla 2). La estimacin de ingesta energtica, de macronutrientes y minerales a excepcin de calcio permaneci constante entre la primera medicin y despus de dos meses de seguimiento.

Aunque la estimacin de ingesta dietaria de calcio pre-sumiblemente aument por efecto de la consejera virtual

y presencial, el 95% de las participantes no logr cubrir el porcentaje de adecuacin esperado al fi nal de la intervencin, la media del porcentaje de adecuacin (PA) fi nal para calcio fue 68 19% (tabla 3).

DISCUSINEl presente estudio encontr un aumento signifi cativo

en las ingesta estimada de calcio en mujeres en edad frtil del Sur Oriente de Santiago de Chile. Sin embargo, aunque la consejera aumento la ingesta de calcio, esta no fue sufi ciente para cubrir los requerimientos, siendo bajo el 50% del EAR esperado (1000 mg/da) en las tres mediciones realizadas (3).

La consejera nutricional sera una intervencin a conside-rar para mejorar los conocimientos y la adherencia a ptimos patrones alimentarios de la poblacin. Existe evidencia de que la consejera nutricional puede promover una dieta saludable as como mejorar el comportamiento diettico, incluyendo la reduccin de las grasas saturadas y el aumento de las ingesta de frutas y vegetales (23,24). Varios estudios han reportado el efecto de la consejera nutricional sobre el incremento en la ingesta de calcio (25,26). En nuestro estudio el incremento observado, respecto al da 1 fue (delta) 47 94 mg/d al da

TABLA 1

Caractersticas antropomtricas de las mujeres del estudio1. Variables (n=20) Da 1 Da 62 Ta p

Talla (m) 1,56 0,07 - - -

Edad (aos) 39,3 4,5 - - -

Peso (Kg) 62,3 6,7 62,6 6,7 -0,20 0,84

IMC 25,6 3,2 25,8 3,0 -0,14 0,89

1Valores presentados como media desviacin estndar aValor de la prueba t de Student para muestras pareadas a dos colas IMC= ndice de masa corporal

TABLA 2

Ingesta de energa, macro y micronutrientes en las mujeres del estudio.

Consumo da Evaluacin 1 Evaluacin 2 Evaluacin 3 F p

Energa (Kcal/d) 1877 287 1989 381 1982 360 1,11 0,34

Carbohidratos (g/d) 209 40 219 42 222 52 0,74 0,48

Protenas (g/d) 57 15 64 21 61 16 1,16 0,32

Grasas (g/d) 90 12 95 26 95 17 0,77 0,47

Fibra (mg/d) 4 2 3 2 4 3 1,66 0,20

Hierro (mg/d) 11,1 2,9 12,4 3,1 12,0 3,2 1,70 0,20

1Calcio (mg/d) 308 116a 354 138b 412 188c 4.43 0.02

Fsforo (mg/d) 720 160 803 234 817 220 2,22 0,12 Sodio (mg/d) 1298 398 1329 492 1352 376 0,25 0,78

Valores presentados como promedios desviacin estndar. 1Ingesta de calcio dietario ANOVA medidas repetidas; Bonferroni, test de comparacin mltiple (evaluacin 3 vs evaluacin 1 p

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30 y 103 169 mg/d al da 62.En el presente estudio se observ que la consejera nu-

tricional realizada virtualmente podra ser til en incrementar las ingesta de calcio dietario diario. Similar a nuestro hallazgo, otros autores han evaluado los efectos que tiene sobre el consumidor el uso de internet para tomar decisiones, mejo-rar conocimientos, actitudes y utilizacin de la informacin sobre temas de salud, reportndose efectos positivos en los programas de educacin nutricional y prdida de peso (17). Por su parte, Asakawa y cols (2011), en un estudio en Japn que incluy 182 mujeres saludables de 18 a 25 aos de edad con un seguimiento de 6 meses, en el cual se buscaba deter-minar si la intervencin nutricional a travs del internet era capaz de incrementar la resistencia sea, observ un aumento en el promedio de la ingesta dietaria diaria de calcio, siendo el cambio respecto al perodo basal de 216,3 85,9 mg/da adicionales en el grupo intervenido (27).

Desde un punto de vista preventivo, sera recomendable promocionar un aumento de la ingesta dietaria de calcio a toda la poblacin, mediante campaas de educacin pblica utilizando estrategias de comunicacin social masiva tradi-cionalmente empleadas en la publicidad comercial, as como tambin, promocin del consumo de alimentos ricos en calcio (tabla 4) con bajo contenido de grasas, a fi n de cumplir con la EAR para este mineral.

En Chile, consistente con nuestro resultados, Aguirre y cols (2007) en un estudio en mujeres obesas reportaron una in-gesta inferior al 50% de las EAR, tanto al inicio como al fi nal de la intervencin (540 287 y 480 209 mg/d, respectivamente) (12). De igual manera, Castillo y cols (1997), en otro estudio sobre patrones alimentarios en la Regin Metropolitana de Chile, observaron que la ingesta de calcio estaba bajo el 50% en adultos que asisten a centros de atencin primaria (11). Esta tendencia defi citaria de ingesta de calcio se observ tambin en grupos vulnerables, como las adolescentes en perodo de lactancia (10,28). En general, varios estudios demuestran una baja ingesta de calcio en las mujeres chilenas (11,12).

El bajo consumo de calcio en la dieta, inclusive entre

aquellas mujeres en estados fi siolgicos comprometidos (em-barazo y lactancia), est muy relacionado a sus conocimientos y creencias propias. Se ha descrito que el nmero de hijos, la puntuacin de la autopercepcin de la salud, el IMC, el nivel de educacin, y las experiencias con exmenes relacionados a la salud sea e historia familiar explican en su conjunto 31,8% de la variacin de la ingesta de calcio (29). Otros factores relacionados al bajo consumo de calcio y su biodisponibilidad estn ligados a las actitudes y pensamientos negativos hacia el calcio y al consumo de caf (30).

En Chile, otro elemento importante a analizar respecto a la ingesta de calcio es la dureza del agua, ya que este factor aumenta la estimacin de la ingesta de calcio en la dieta. El contenido promedio de calcio en el agua de la regin Sur Oriente de Santiago es de 133,91 mg/L (31). Al considerar en nuestro estudio el aporte de calcio de una ingesta promedio de agua de aproximadamente 2 L/da, la ingesta diaria de calcio al da 62 aumentara de 412 a 679 mg/d. El contenido de calcio en el agua es variable y depende de la naturaleza geolgica del rea donde se asienta el acufero y su asociacin con cuencas de captacin de rocas sedimentadas. La dureza del agua se debe a cationes metlicos divalentes, entre ellos el calcio, que se combinan con aniones. Sin embargo, es necesario realizar un anlisis ms profundo de la relacin entre la ingesta de calcio y el consumo real de agua en esta poblacin.

Chile ha experimentado una rpida transicin nutricional durante los ltimos aos, caracterizada por una disminucin de la tasa de desnutricin primaria e incidencia de mortali-dad materno-infantil. Sin embargo, estos cambios han sido acompaados por un dramtico aumento en la prevalencia de sobrepeso y obesidad, relacionado con una alta ingesta de grasas, azcares simples y sodio, y bajos niveles de activi-dad fsica, coexistiendo con defi ciencias de micronutrientes (32). En ese sentido, nuestros resultados indican que hay un consumo elevado de energa y un bajo consumo de mi-cronutrientes, en particular de calcio. Recientemente se ha relacionado la ingesta adecuada de calcio con la prevencin de exceso de adiposidad corporal, hipertensin arterial

TABLA 3

Adecuacin macronutrientes y macro minerales de la ingesta al fi nal (da 62) en mujeres de 35-45 aos de edad.

EAR1 media DE media DE de N(%) de sujestos segn adecuacin de ingesta PA2 (%) 110% (90-110%)

Caloras cal/d 1600-1700 1982 360 120 22 2(10%) 6(30%) 12(60%)

Proteina g/d 46 61 16 133 35 - 6(30%) 14(70%)

Carbohidratos g/d 130 222 52 171 40 - 1(5%) 19(95%)

Grasas g/d 53 95 17 179 33 - - 20(100%)

Fibra g/d 25 4 3 17 12 20(100%) - -

3Calcio mg/d 1000 677 205 68 19 1(5%) 1(5%) 18(90%)

Hierro mg/d 18 12 3 67 18 18(90%) 2(10%) -

Fsforo mg/d 700 834 235 117 32 3(15%) 7(35%) 10(50%)

Sodio mg/d 1500 1000 380 90 25 8(40%) 7(35%) 5(25%)

1EAR: promedio requerido estimado 2PA: porcentaje de adecuacin 3Considera la ingesta diettica de calcio despus de 62 das de intervencin y el aporte de calcio del agua en Chile.


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(HTA), enfermedad cardiovascular (ECV) e resistencia a la insulina (33,34).

Como fortalezas del presente estudio se puede mencionar que se hicieron mediciones en tiempos diferentes y se logr obtener repetibilidad de los datos observados en el resto de variables evaluadas, enfatizando la idea de que los cambios encontrados en la ingesta de calcio fueron efecto de la conse-jera nutricional impartida (presencial y virtual). De la misma manera, nuestro hallazgo podra validar la aplicacin del CFCSC a travs de internet. Igualmente, si bien se ha recomendado la tcnica por recordatorio de 24 horas para medir ingesta dietara, sta metodologa tiene la desventaja de que slo mide

ingesta de un da, o por su complejidad, de un corto perodo de tiempo. Por su parte, el CFCSC nos permite un estimado de la ingesta del ltimo mes, siendo el mtodo ms adecuado para este tipo de anlisis.

El anlisis presentado en el este artculo corresponde a un objetivo secundario de un estudio diseado con el propsito de evaluar la absorcin de hierro en presencia de calcio. Sin embargo, representa una oportunidad de evaluar el efecto de la consejera sobre el consumo de alimentos con alto conte-nido de calcio. El diseo del estudio no cont con un grupo control. La ausencia de grupo control debilita el suponer que el aumento observado de alimentos con alto contenido de

TABLA 4

Alimentos chilenos seleccionados con alto contenido de calcio.

Alimento Calcio (mg) en 100 g

Leche en polvo 26% grasa 1230 Leche en polvo 12% grasa 1020 Leche en polvo descremada 1020 Leche evaporada 231 Leche de vaca pasteurizada 123 Yogurt natural 150 Yogurt batido simple 145 Yogurt con sabor 127 Yogurt con frutas 105 Yogurt dieta 117 Queso gouda 1076 Queso cabra 626 Quesillo 487 Leche Purita 912 Leche Purita Cereal 500 Leche Purita Modifi cada 500 Sardina en aceite 374 Sardina en salsa 262 Choritos 202 Pejerrey 147 Macha 87 Acelga cruda 124 Brcoli 103 Acelga cocida 101 Aceituna 87 Frejol cocido 260 Soya 197 Frejol crudo 164 Haba seca 141 Garbanzo crudo 134 Poroto granado 96 Garbanzo cocido 78 Almendra 294 Higos 180 Avena 148 Semola 117 Man salado 105

Fuente: Tabla de Composicin Qumica de Alimentos en Chile.


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calcio es atribuible a la consejera virtual y presencial. Factores socioeconmicos pueden infl uenciar cambios en la ingesta diettica. Por otro lado, no se evalu el estado nutricional de calcio a travs de determinaciones bioqumicas. Lo anterior, implica que los cambios dietarios no necesariamente impli-can mejoras en el estado nutricional de este mineral. Aun considerando estas limitaciones, nuestro estudio muestra un alto porcentaje de inadecuacin dietaria en la lnea de base y al fi nal del estudio. Existiendo un aumento en la ingesta de alimentos con alto contenido de calcio no se lograra una adecuacin dietaria al efectuar la consejera. Sin embargo, es importante reconocer que existen grandes difi cultades en traducir el reporte de ingesta dietaria a su aporte diario, dado que las tablas de composicin qumica de alimentos en general se desarrollan en base a otros alimentos, dada las diferencias en biodisponibilidad de los nutrientes.

La realizacin de la estimacin de la ingesta de manera virtual podra presentar ciertas desventajas, en particular consi-derando aquellas mujeres sin acceso a este tipo de tecnologa. En nuestro estudio, las encuestas se aplicaron al da 30 y 62, a travs de una aplicacin Google Drive, resultando en que ocho de las 28 participantes no pudieran completar el estudio debi-do a que no contaban con acceso a internet, ya sea por falta de equipo o por conocimientos de cmo utilizarlo; as tambin, limitaba a estas participantes de reforzar y/o preguntar va internet a travs del grupo en redes sociales. Por lo tanto, los resultados slo podran ser representativos de personas con acceso a tecnologas de informacin y comunicacin. De igual manera, coincidentemente el nivel socioeconmico bajo podra presentar una ingesta de calcio menor. El sesgo del recuerdo tambin puede ser considerado como una limitante debido a que el CFCSC depende de la memoria.

Por ltimo, pudiera ser considerada tambin como una limitante ms del estudio el hecho de que no se logr aumentar la ingesta de calcio a una signifi cancia clnica o al menos a ms del 50% de la ingesta recomendada de 1000 mg/d. Por otro lado, se podra considerar que el CFCSC como mtodo de estimacin de la ingesta sobreestima el valor de la misma (35). Esto puede deberse a que el CFCSC permite el reporte de alimentos que no son ingeridos con regularidad por la pobla-cin estudiada (35,36). Adems, el tamao de la porcin, que al no ser adecuada a la poblacin en estudio, podra conducir a la inexactitud en la cuantifi cacin de la ingesta (37).

Conclusin: La consejera nutricional podra aumentar la ingesta de alimentos fuentes de calcio en mujeres en edad frtil chilenas. No obstante, la ingesta dietaria estimada de calcio al fi nal de la intervencin no alcanz ms del 50% de los requerimientos.

RESUMENEl calcio juega un rol crucial en la regulacin de procesos

metablicos, especialmente en la funcin neuromuscular y en la salud sea. Sin embargo, la ingesta dietaria de calcio en mujeres en edad frtil de Chile no cubre los requerimientos. Objetivo: determinar s la consejera nutricional presencial y virtual incrementa la ingesta dietaria de calcio en mujeres chilenas de edad frtil. Sujetos y mtodos: la ingesta dietaria de calcio en 20 mujeres (edad media de 39 5 aos) antes y despus| de una intervencin de educacin alimentaria y nutricional fue comparada. La consejera nutricional fue im-partida para promover el consumo diario de alimentos ricos en calcio. Adems, se habilit un espacio virtual para reforzar la consejera nutricional. En el da 1, 30 y 62 se aplicaron cuestionarios de frecuencia de consumo semi-cuantitativos.

La ingesta dietaria de calcio increment signifi cativamente (ANOVA F = 4.43, P= 0.02) despus de la intervencin. La ingesta dietaria de calcio fue 308 116mg/d al da 1, 354 138mg/d al da 30, e increment a |412 188mg/d despus de 62 das. Al fi nal de la intervencin, el 95% de las partici-pantes no cubrieron sus requerimientos diarios de calcio; la media del porcentaje de adecuacin para la ingesta de calcio fue 68 19%. La consejera nutricional podra incrementar la ingesta dietaria de calcio en mujeres de edad media en Chile. Sin embargo, el aumento no es sufi ciente para cubrir los requerimientos de calcio.

Palabras clave: calcio, micronutrientes, ingesta dietaria, requerimientos nutricionales, consejera nutricional.

Agradecimientos: Los autores agradecen a las participan-tes del estudio por su colaboracin, as como tambin a las Nu-tricionistas Paulina Castiglioni por su apoyo en la recoleccin y codifi cacin de los datos alimentarios y antropomtricos. El estudio fue fi nanciado por el Proyecto FONDECYT 1095038, Santiago, Chile.

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INTRODUCTIONProtein-energy malnutrition is frequently found in pa-

tients with advanced liver disease (1). It is described in 50 to 100% of patients with decompensated cirrhosis and in at least 25% of those with compensated cirrhosis( 2-4). Protein-energy malnutrition leads to serious consequences for the patients general condition and clinical evolution (3, 5, 6), Nutritional supplementation has been associated with reduced infection

Caractersticas clnicas y delaboratorio en pacientes cirrticosasociada con desnutricinm oderada o severa

Clinical and laboratorycharacteristics of cirrhotic patientsassociated with moderate andsevere malnutrition


Samantha Thifani Alrutz Barcelos (1)Esther Buzaglo Dantas-Corra (1)

Maria Luiza Aires Alencar (2)Leonardo de Lucca Schiavon (1)

Janaina Luz Narciso-Schiavon (1)

(1) Ncleo de Estudos em Gastroenterologia e Hepatologia (NEGH),Universidade Federal de Santa Catarina (UFSC), Florianpolis, Santa Catarina, Brazil.

(2) Ncleo de Pesquisa de Nutrio em Produo de Refeies (NUPPRE),Hospital Universitrio Polydoro Ernani de So Thiago,

Universidade Federal de Santa Catarina (UFSC), Florianpolis, Santa Catarina, Brazil.

Author correspondence: Janana Luz Narciso-Schiavon

Departamento de Clnica Mdica Universidade Federal de Santa Catarina (UFSC)

Hospital Universitrio Polydoro Ernani de So Thiago, Rua Professora Maria Flora Pausewang, s/no, 3o andar

Trindade Florianpolis (SC , Brasil CEP 88040-900

Tel. (+55 48) 3721-9149E-mail: [email protected]

Este trabajo fue recibido el 12 de Noviembre de 2013y aceptado para ser publicado el 30 de Enero de 2014.

ABSTRACT Context and objective: Protein-energy malnutrition is described Context and objective: Protein-energy malnutrition is described in 25-100% of patients with cirrhosis. The aim of this study was to evaluate the nutritional status of cirrhotic patients, to identify clinical and laboratory variables associated with moderate to severe malnutrition and to correlate them with cirrhosis prognostic factors (Child-Pugh Classifi cation). Design and setting: This cross-sectional study evaluated cirrhotic individuals admitted to University Hos-pital from December 2011 to August 2012. Methods: Nutritional status was evaluated by Subjective Global Assessment (SGA), total lymphocyte count and serum albumin. Bivariate analysis was used to identify variables associated with Child C and with moderate to severe malnutrition in different nutritional classifi cations. Results: Sixty-seven patients were included (mean age 54.4 11.7 years; 74.6% men). The mean MELD score was 14.5 6.5, and almost 30% of the individuals were classifi ed as Child C. With respect to nutritional status, 20.9% showed severe malnutrition by SGA, 14.9% malnutrition by total lymphocyte count, and 40.3% by albumin levels. In all methods employed, moderate to severe malnutrition was correlated with Child classifi cation grade C. The rate of moderate to severe malnutrition by SGA was lower than that evidenced by laboratory methods. Nevertheless, SGA indicated a greater proportion of Child C patients with moderate to severe malnutrition. Conclusion: Due to the high prevalence of malnutrition and its correlation to the severity of cirrhosis, the nutritional evaluation of cirrhotic patients is an essential step that can be performed through simple methods in routine hospital care.Key words: Liver cirrhosis, lymphocyte count, malnutrition, nutrition assessment, serum albumin.

risk and intra-hospital mortality, as well as the improvement of liver function (7, 8).

Multiple factors contribute directly to the malnutrition that frequently affects patients with cirrhosis: poor food intake, regardless of the diseases stage, secondary to ano-rexia, early satiety, and restrictive diets (low-sodium and/or low-protein diets); changes in the synthesis, metabolism and storage of nutrients; and poor digestion and absorption

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of nutrients or even hypermetabolism (9,10). Moreover, the intensity of gastrointestinal symptoms is related to the severity of the liver disease and leads to reduced quality of life (11).

Some studies have investigated methods of nutritio-nal evaluation in individuals with cirrhosis by means of anthropometric measurements, most commonly the triceps skinfold thickness, mid arm circumference and mid arm muscle circumference; the use of a dynamometer or the non-dominant hand grip-strength; electrical bioimpedan-ce; indirect calorimetry; biochemical measurements such as hemoglobin, total lymphocyte count (TLC) and albumin count; and clinical nutritional evaluation, carried out by the Subjective Global Assessment of Nutritional Status (SGA) (1,2,12-14).

There is no gold standard that is capable of precisely diagnosing the alterations in the nutritional state of patients with cirrhosis(10,12). Several of the clinical manifestations of malnutrition are only consequences of liver dysfunction (1,14, 15), such as fl uid retention, edema and ascites. These altera-tions are seen as major limiting factors to the predictive value of the common nutritional evaluation methods. It is diffi cult to apply the percentage of ideal body weight and body mass index parameters because they underestimate the severity of the malnutrition and its prevalence. However, combining distinct methodological approaches to indication (clinical, anthropometric, biochemical, dietetic, functional) reduces these restrictions (12,16).

The SGA, modifi ed by Detsky et al. (17), is a practical method to obtain a nutritional diagnosis of cirrhotic patients when access to objective nutritional evaluation data is restricted (10). This is a simple, low-cost, practical method that attains the nutritional diagnosis of the patient. It can be carried out in a few minutes at the patients bedside and may be applied by any of several health professionals (e.g., a doctor, nutritionist, or nurse) with easy reproducibi-lity(10,17). The SGA is used in the nutritional evaluation of individuals with cirrhosis to classify their malnutrition and to predict their clinical evolution (18). Barbosa-Silva and Barros validated the SGA as a good option for the nutritional evaluation of individuals with liver disease (16). It is also one of the nutritional evaluation methods recommended by the European Society for Clinical Nutrition and Metabolism for the identifi cation of cirrhotic patients at high risk of malnutrition (19).

Although the TLC is a widely used immunity test to eva-luate immune competence, it has also been considered an effective test of nutritional status (10). Despite the controversy concerning its ability in diagnosing malnutrition (20,21), this test has frequently been applied for this purpose in individuals with cirrhosis, often in association with other parameters(1, 22-26). Considered a reliable parameter in nutritional eva-luation, albumin has diminished synthesis and accelerated catabolism in individuals with cirrhosis (10,21). Albumin has also been used by several authors as a signal of malnutrition in this group of patients (2,27).

OBJECTIVEThis study aimed to evaluate the nutritional status of

cirrhotic patients by subjective (SGA) and objective (labo-ratory and anthropometric) parameters to identify clinical and laboratory variables associated with moderate to severe degrees of malnutrition and to correlate them with cirrhosis prognostic factors.

SUBJECTS AND METHODSPatients

This descriptive cross-sectional study included consecuti-ve individuals with cirrhosis admitted to the University Hospital of Santa Catarina from December 2011 to August 2012. All patients were evaluated in the fi rst three days of hospitaliza-tion. Patients with congestive heart failure, chronic pancreatitis or human immunodefi ciency virus (HIV) were excluded. Those with more than one hospitalization for the same purpose and those who presented hepatic encephalopathy in stage III or IV were also excluded.

The study protocol conformed to the ethical guidelines of the 1975 Helsinki Declaration and was approved by our institutional review board under number 2443/11. Written informed consent was obtained from all subjects before study enrollment.

|Methods

Clinical, laboratory and histological fi ndings were collec-ted from physical examination, interviews and medical records. The following clinical and demographic characteristics were recorded: age (years); gender; race; cirrhosis decompensation at the moment of hospitalization as a result of upper digestive bleeding, hepatic encephalopathy, ascites, or spontaneous bacterial peritonitis; and the presence of comorbidities (pneumonia) or bleeding (gingivorrhagia or ecchymosis). The etiology of the cirrhosis was defi ned by laboratory, serological and molecular biology tests. HBsAg-positive individuals were considered carriers of hepatitis B virus, and those who were HCV-RNA positive were considered carriers of hepatitis C virus. Alcoholism was defi ned as the intake of 60 grams of ethanol per day for both women and men (28). The severity of the liver disease was evaluated by the Child-Pugh classifi cation at the same time as the nutritional evaluation (29), and it was evaluated by the Model of End-Stage Liver Disease (MELD) score at the same time as the laboratory test results were recorded on the medical charts (30).

The following laboratory variables were measured: he-moglobin, serum albumin, lymphocyte count, platelet count, international normalized ratio (INR), prothrombin activity, total bilirubin (TB), creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT). The hepatic-function-related biochemical parameters AST, ALT, ALP and GGT are expressed as multiples of the upper limit of normal (xULN). The other laboratory variables are expressed as absolute values. TB, INR and creatinine were used for the MELD calculation. Only laboratory tests performed during hospitalization were considered in this study. All data were collected by the fi rst author.

Nutritional evaluationThe nutritional condition was studied on the basis of

the following nutritional evaluation methods: SGA, hemato-logical (TLC) and biochemical (albumin) indicators (2,17,21). Subjective and anthropometric data for SGA were collected and classifi ed by a medical student under the supervision of a nutritionist and calculated using a questionnaire adapted from Detskys proposal (21). The following aspects of the patients clinical history were evaluated: weight change in the last six months (either increase or decrease), alterations in dietary intake, and presence of dyspeptic symptoms for more than two weeks and functional capacity with regard to the degree of stress caused by the disease. Although the literature shows

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great divergence on this matter (31-34), we considered all evaluated cirrhotic individuals to be presenting a moderate degree of stress. The parameters considered during physical examination included loss of subcutaneous fat, muscle loss, presence of malleolar edema, presacral edema and ascites.

The usual body weight element of the SGA is reported by the patient. In this study, the current weight was measured with the use of a portable mechanical scale (Mallory mark, model 14578-01)|with a maximum capacity of 120 kg, a mi-nimum of 1 kg, and an accuracy of 0.05 kg. From this weight, the water weight was subtracted per Jamess estimation (35), according to the intensity of the ascites and according to the peripheral edema, if present. Thus, the weight without the edema and ascites was obtained, and this measurement was considered the current weight (for the SGA).From the habitual weight reported by the patient and the current weight (the weight without edema and ascites), the percentage of weight loss was calculated.

The test for the loss of subcutaneous fat was performed with then on-dominant arm, which hung close to the patients body and was examined by gripping the patients arm fl exure. Muscle loss was examined on the basis of the verifi cation of the temporal and clavicular regions and forced adduction of the thumb and index fi nger. Based on the score of each parameter, patients were classifi ed as adequately nourished, moderately malnourished or severely malnourished.

TLC was obtained by an automated method, the Sysmex XE-2100 Analyzer. The lysing reagent used for the differential leukocyte count was Stromatolyser-4DS, and the reagent used on diluted and lysed blood samples was Stromatolyser-4DL.

The albumin method employed here was an adaptation of the bromocresol purple binding method described by Carter (36) and Louderback et al (37). The sample collection, reagent

dispersion, mixture, processing and result interpretation are automatically executed by the Dimension system.

On the basis of the laboratory results, different degrees of malnutrition were defi ned. In TLC, mild malnutrition was considered to correspond to values of 1,200 to 2,000 lympho-cytes/mm3; moderate malnutrition, 800 to1,199 lymphocytes/mm3; and severe malnutrition, lower than 800 lymphocytes/mm3 (38). Patients with albumin higher than 3.5 g/dl were considered normal; 3.0/dL to 3.5 g/dL, mildly malnourished; 2.4 g/dL to 2.9 g/dL, moderately malnourished; and lower than 2.4 g/dL, severely malnourished (39).

|Statistical analysis

Continuous variables were compared using Students t test or the Mann-Whitney test, when appropriate. Categorical variables were compared using the chi-square test or Fishers exact test when necessary. A P-value less than 0.05 was con-sidered statistically signifi cant. Bivariate analysis was used to identify variables associated with Child-Pugh class C and with moderate to severe malnutrition in different nutritional classifi cations. Statistical analysis was performed using the Statistical Package for the Social Sciences, version 11.0 (SPSS Inc., Chicago, IL, USA).

|RESULTS

|Patient characteristicsFrom December 2011 to August 2012, 86 patients were

evaluated for inclusion in the study because they presented cirrhosis. Six individuals were excluded for the following co-morbidities: congestive heart failure (n= 1), chronic pancreatitis (n= 1) and HIV (n= 4). Eleven patients were also excluded for presenting more than one hospitalization, and 2 patients were excluded for hepatic encephalopathy of stage III-IV (fi gure 1).

FIGURE 1

Flow diagram of the potential candidates for participation in the study, reasons for exclusion, and subjects enrolled.

Liver Cirrhosisn= 86

Included patientsn= 67

cardiac failure (n= 1) chronic pancreatitis (n= 1) Aids (n= 4) More than one admission for the same reason (n= 11) Hepatic encephalopathy III-IV (n=2)

Excluded

Caractersticas clnicas y de laboratorio en pacientes cirrticos asociada con desnutricin m oderada o severa

142

The characteristics of the 67 consecutive patients included in the study are summarized in table 1. The mean age was 54.4 11.7 years, 74.6% of the patients were men and 91.0% were Caucasian. Approximately 30% of the individuals were classifi ed as Child-Pugh C. The mean MELD score was 14.5 6.5. More than half of the individuals presented ascites during hospitalization, 41.8% presented high digestive bleeding, 1/3 showed hepatic encephalopathy and only 3% were diagnosed with spontaneous bacterial peritonitis. With regard to the etiology of the cirrhosis, 43.3% presented alcoholism, 34.3% hepatitis C and 10.4% hepatitis B.

Regarding nutritional evaluation (table 2), 20.9% of the samples were classifi ed as suffering from severe malnutrition by the SGA. Fifteen percent of the patients showed severe malnutrition, as indicated in the TLC, and 40.3% presented se-rious malnutrition, as indicated by the albumin concentration.

Evaluation of individuals included accordingto the Child-Pugh classifi cation

When Child-Pugh C individuals were compared to those classifi ed as Child-Pugh class A/B, the former presented lower mean weight that was free from edema and ascites (64.4 17.4 versus 73.5 16.5 kg; P = 0.045). A greater proportion of Child-Pugh C individuals had lost more than 10% of body

weight (61.9% versus 34.8%; P = 0.038), had been prescribed changes in diet (81% versus 50%; P = 0.017), had modifi ed their diet for more than 30 days (75.0 versus 32.6%; P = 0.001) and had fasted for more than 5 days (33.3% versus 6.5%; P = 0.008). The Child-Pugh C patients also presented a higher frequency of physical capacity below normal for more than two weeks (76.2% versus 50%; P = 0.044), loss of subcutaneous fat (71.4% versus 43.5%; P = 0.034) and edema of either the ankle (76.2% versus 41.3%; P = 0.008) or sacrum (52.4% versus 17.4%; P = 0.003). With regard to the nutritional eva-luation (table 3), a higher proportion of moderate or severe malnutrition was observed among Child-Pugh C individuals according to the SGA (P < 0.001), albumin (P = 0.006) and TLC criteria (P = 0.024). The proportion of individuals with moderate to severe malnutrition did not differ between the Child-Pugh C and Child-Pugh A-B groups (P = 0.192).

|Evaluation of included individuals in accordance

with the nutritional classifi cationsWhen we compared the individuals who were classifi ed

as suffering from moderate to severe malnutrition by the SGA to the others (table 4), we observed that the former presen-ted greater rates of ascites (80.0% versus 35.1%; P < 0.001), hepatic encephalopathy (43.3% versus 18.9; P = 0.030) and

TABLE 1

Clinical characteristics and biochemical profi le of 67 patients with cirrhosis. Characteristics of the sample Age (years)* 54.4 11.7 (54) Male, n (%) 50 (74.6) Caucasian, n (%) 61 (91.0) MELD* 14.5 6.5 (13.0) Child-Pugh classifi cation - A, n (%) 12 (17.9) - B, n (%) 34 (50.7) - C, n (%) 21 (31.3) Cirrhosis decompensation on admission - Ascites, n (%) 37 (55.2) - Upper digestive bleeding, n (%) 28 (41.8) - Hepatic encephalopathy, n (%) 20 (29.9) - Spontaneous bacterial peritonitis, n (%) 2 (3) Laboratory exams - Hemoglobin (g/dL)* 11.3 3.3 (11.1) - Albumin (g/dL)* 2.6 0.6 (2.5) - Platelets (/mm3)* 108,238.8 78,292.0 (92,000.0) - PA (%)* 54.4 17.4 (53.6) - Total bilirubin (mg/dL) * 3.4 5.7 (1.5) - Creatinine (g/dL) * 1.3 1.0 (1.1) - AST (xULN) * 6.0 28.6 (1.7) - ALT (xULN) * 1.7 3.8 (0.8) - ALP (xULN) * 1.0 0.7 (0.9) - GGT (xULN) * 3.0 4.0 (1.6)

MELD= Model of End-Stage Liver Disease; PA= prothrombin activity; AST= aspartate aminotransferase; ALT= alanine aminotransferase; ALP= alkaline phosphatase; GGT= gamma glutamyl transferase; xULN= times the upper limit of normal; *mean standard deviation (median).

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Child-Pugh class C diagnosis (56.7% versus 10.8%; P

144

predominance (41), similar to the present sample. Regarding prognostic classification, 18% of the studied individuals were classifi ed as Child-Pugh A, 51% as B and 31% as C. This distribution is similar to that described by some authors: Child-Pugh A varies between 15.3% to 17.3% (1,2), and most of the patients are classifi ed as Child-Pugh B (56.7%) (1). The prevalence of Child-Pugh class C may vary widely, from 3.4% (12) to 48.7% (2), while similar frequencies to ours have also been reported (26%-30%) (1,32). While Gottschall et al. (14) reported that most patients (61.8%) presented MELD scores between 10 and 19, Gunsar et al. (5) reported that patients median MELD score was 15 (6-56), and both studies showed similar values to those in the present study (14.5 6.5).

In the present study, individuals with moderate to severe malnutrition according to the SGA, albumin and TLC criteria were mainly classifi ed as Child-Pugh C (67-95%). Child-Pugh C patients are malnourished by defi nition (42). Gunsar et al. (5) observed a 57% rate of malnutrition among 222 cirrhotic individuals, whereas those who were seriously malnourished were more inclined to have moderate ascites and higher Child-Pugh scores compared to those who were well nourished. Gunsar et al. (5) also noted a higher frequency of encephalo-pathy of stages I and II among the malnourished, as observed in the present study. Roongpisuthipong et al. (6) observed that the prevalence of protein-energy malnutrition increases as the severity of the illness increases and that protein-energy

malnutrition is much more prevalent in Child-Pugh C patients than in Child-Pugh A and B patients. In one study that eva-luated a small proportion of Child-Pugh C outpatients (3%), no nutritional classifi cation was able to detect an association between malnutrition and severity of liver disease (Child-Pugh) (12). Hence, one could expect that when the majority of the individuals evaluated in a study are classifi ed as Child-Pugh A or B, low malnutrition rates will be found. Contrary to this expectation, although 69% of the hospitalized individuals in this study were classifi ed as Child-Pugh A-B, severe malnutri-tion was detected in 15% to 48% of the cirrhotic individuals, depending on the method applied.

The signs associated with chronic liver disease, such as ascites, edema, altered immunocompetence, decreased pro-tein synthesis and renal insuffi ciency may alter the objective criteria traditionally used in nutritional assessment. Thus, weight loss; anthropometric measurements; creatinine-height index; balanced nitrogenous excretion of 3-methyl-histidine; sensitivity tests of cutaneous lymphocyte count; and serum albumin, transferrin, prealbumin, and retinol-binding protein must be interpreted in the context of the nutritional status of these patients. However, most of these alterations refl ect the progression of liver disease. Regardless, SGA seems to be the most suitable instrument for diagnosing malnutrition in cirrhotic patients (16). When50 cirrhotic outpatients were evaluated by Silva and Silveira (42), 88% were classifi ed as

TABLE 4

Comparative analysis of the laboratory and clinical characteristics of 67 patients with liver cirrhosisby the nutritional profi le of Subjective Global Assessment.

Moderately/severely malnourished Well nourished P n= 30 n= 37 44.8% 55.2%

Age* 55.0 12.1 53.8 11.4 0.673t

Male, n (%) 22 (73.3) 28 (75.7) 0.827q

Caucasian, n (%) 29 (96.7) 32 (86.5) 0.213f

Cirrhosis decompensation on admission, n (%) 27 (90.0) 29 (78.4) 0.321f

UDB, n (%) 11 (36.7) 17 (45.9) 0.444q

HE, n (%) 13 (43.3) 7 (18.9) 0.030q

Ascites, n (%) 24 (80.0) 13 (35.1)

145

Child-Pugh A and 12% were Child-Pugh B, with a prevalence of malnutrition of up to 63% according to handgrip strength and 28% according to SGA, demonstrating a high prevalence of malnutrition in cirrhotic outpatients and a large discrepancy between nutritional evaluation tools. Handgrip strength, but not SGA, predicted a poorer clinical outcome in patients with cirrhosis because major complications occurred in 65.5% of malnourished patients versus 11.8% of well-nourished ones (P < 0.05).

However, some studies have demonstrated that the SGA has low sensitivity for the diagnosis of malnutrition. Gottschall et al. (14) evaluated 34 cirrhotic patients, 21% of whom were classifi ed as Child-Pugh C. The prevalence of malnutrition was 35% by the SGA method, which was much higher than the prevalence estimated by other methods applied in their study, such as triceps skinfold (18%) and upper arm circumference (6%). Figueiredo et al. (40) assessed 79 cirrhotic patients, 72% of whom were classifi ed as Child-Pugh Thirty-two percent were malnourished according to SGA, 30% were malnourished according to a traditional model, and 60% were malnourished according to the multicompartmental model. Once again, SGA misclassifi ed malnutrition in two-thirds of the patients, mainly those with better liver function. It is conceivable that this fi nding occurred because the SGA does not classify mild malnutrition. Patients with a mild stage of malnutrition are classifi ed as eutrophic, which may represent a mistake (43). In the present study, SGA classifi ed 50% of the evaluated in-

dividuals as well-nourished, while other methods considered 8-30% of the patients to be eutrophic. It is recommended that the SGA be carried out within three days after hospitalization so that possible problems related to hospitalization and intra-hospital malnutrition can be prevented (21). Hence, all patients in this study were evaluated within three days of admission.

Moderate to severe malnutrition was diagnosed by albu-min classifi cation in 73.1% of the studied patients. Decrease of serum albumin levels in patients with liver cirrhosis usually refl ects liver synthesis disfunction and also is associated with malnutrition, due to food intake restriction and to the worsening metabolism of nutrients (44). Total lymphocytes count values were compatible with the diagnosis of modera-te to severe malnutrition in 46.2% of the assessed patients. However, it is well known that the TLC evaluates immune competence and can be infl uenced by additional factors other than nutritional status, such as hiperesplenism and infections (45). These variables were not evaluated in the present work and are usually more frequent in advanced liver disease. The presence of hypersplenism could have contributed to the grea-ter frequency of diagnosis of moderate to severe malnutrition by the TLC method among Child-Pugh C patients. Despite the ambiguity of biochemical markers, they have been widely used in the nutritional assessment of patients with liver cirrhosis (1,3,4,22-26).

In 48 hospitalized patients with chronic liver disease, Pinedo et al. (46) found a positive linear correlation between

TABLE 5

Comparative analysis of the laboratory and clinical characteristics of 67 patients with liver cirrhosisby the nutritional profi le by the classifi cation of total lymphocyte.

Moderate/Severe malnutrition Normal P n= 31 n= 36 Age* 56.0 13.1 52.9 10.2 0.279t

Male, n (%) 24 (77.4) 26 (72.2) 0.626q

Caucasian, n (%) 30 (96.8) 31 (86.1) 0.205f

Cirrhosis decompensation in admission, n (%) 29 (93.5) 27 (75.0) 0.041q

UDB, n (%) 12 (38.7) 16 (44.4) 0.635q

HE, n (%) 10 (32.3) 10 (27.8) 0.689q

Ascites, n (%) 22 (71.0) 15 (41.7) 0.016q

SBP, n (%) 2 (6.5) 0 (0.0) 0.210f

Child-Pugh class C, n (%) 14 (45.2) 7 (19.4) 0.024q

MELD# 15.0 11.5 0.002m

Platelets# 75,000.0 102,000.0 0.042m

Albumin* 2.5 0.6 2.7 0.6 0.099t

PA# 49.3 13.3 58.7 19.4 0.026t

BT# 2.5 1.1 0.001m

Creatinine# 1.1 1.0 0.082m

ALT (xULN)# 0.7 1.0 0.016m

AST (xULN)# 1.5 1.8 0.372m

ALP (xULN)# 0.8 0.9 0.534m

GGT (xULN)# 1.6 1.8 0.474m

UDB= Upper digestive bleeding; HE= Hepatic encephalopathy; SBP= Spontan

Revista Nutricion 41-2

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