Download ESPEN LdV-Nutritional Assessment - Istanbul

Nutritional assessment and computers
Pierre Singer
.
Aim of the lecture:
Understanding of the use of computers in nutrition
Objectives:
Comprehensive description of the patient centered information system
Examples of applications
The patient is generating a very large amount of information and data. With the progress of
computerized systems, communication within hospitals is became patient centered and data
management is focused on patient diagnostic and therapeutic procedures.
Data
+ Purpose
= Information
Information + Understanding = Knowledge
Knowledge + Conviction
= Opinion
Nutritional assessment data should be used for a determined purpose, to reach the maximum
of information, for diagnosis or screening for example. When well understood, this information is
increasing knowledge’s physicians. This knowledge mixed to a conviction becomes an opinion on a
medical condition.
Examples:
Examples can be taken from the energy balance assessment. Datas acquired using
computerized information system in the intensive care is able to achieve a very accurate energy
balance during the hospitalization. The information of a negative energy balance is better
understood when correlation between negative energy balance and complications is found. This
knowledge together with the conviction that we should feed ICU patients is raising the opinion that
tight calorie balance control is mandatory in the ICU
Others examples using computers have been described in the screening of nutritional status
in chronic renal failure patients. Computers have also been used for advising for the best diet in a
computer-tailored nutrition intervention.
Conclusions:
The use of computers in nutritional practice is helpful, time sparing and increasing
knowledge about the nutritional condition of our patients.
History taking, Physical examination
Sadık Kılıcturgay ,
Aim of the lecture:
To realize the signs and the symptoms of nutritional problems
To understand how important to get the history taking and physical examination on the definition of
nutritional problems
To assess a patient for general nutritional status
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Objectives:
At the end of the presentation, the student will be able to:
-Obtain the nutritional aspects of patient history assessing nutritional risk factors, including dietary
intake and utilization and diseases affecting these processes.
-Perform physical assessments
-Perform Subjective Global Assessment (SGA)
Content of the lecture:
History taking,
Physical examination
About 30-50 % of all patients in hospital are malnourished. A large part of these patients are
malnourished when admitted to hospital and in the majority of these, malnutrition develops further
while in hospital.This can be prevented if special attention is paid to their nutritional care. The
history is the starting point for any nutritional assessment. Specific features of note include a recent
weight changes; dietary habits and alteration in dietary intake; allergies and food intolerance;
medications that may effect appetite, gastrointestinal functions and symptoms; current functional
capacity, including recent limitations; and previous medical conditions (any chronic or acute
disease state)
Physical examination is the next step in nutritional assessment. This assessment predominantly
relies on subjective and descriptive information. Although not quantitative, a physical examination
is may still influence the nutritional management of a patient. The main objective of a physical
examination is to establish signs and symptoms of nutrient deficiencies or toxicities, and tolerance
of current nutritional support. A systems approach should be applied using the examination
techniques of inspection, palpation, percussion, and auscultation. The physical examination should
include:
 Assessment of muscle mass and subcutaneous fat stores.
 Inspection and palpation for edema and ascites. These two conditions are important physical
indicators of diminished visceral protein levels and hepatic dysfunction.
 Inspection and evaluation for sings and symptoms of vitamin and mineral deficits, such as
dermatitis, glossitis, cheilosis, neuromuscular irritability, and coarse, easily pluckable hair.
 The patient’s prescribed medication should be examined for potential drug-nutrient
interactions, increased macro-or micronutrient requirements, and nutritionally related side
effects such as constipation, diarrhea, nausea vomiting
The simplest validated nutritional assessment is the SGA, whish is based on patient’s history
and physical examination. Clinicians prefer SGA because of its simplicity, feasbility and
sensitivity that is almost equivalent to objective tests.
Nutritional assessment of patients is not an easy procedure. Although, lots of the clinical and
laboratory measurements are available for nutritional assessment, all of them have lots of
deficiencies. Nutritional assessment is an art more than science. At the current state of the art, in
addition to the physical examination and clinical history, many experienced clinicians solve this
problem by using a few laboratory tests.
References and suggested readings

J. Kondrup J, Allison SP, Elia M.,Vellas B, Plauth M.: ESPEN Guidelines for Nutrition
Screening 2002. Clinical Nutrition 2003; 22: 415–421

Eisenstein C, Van Way CW.: Nutritional Assessment, in Handbook of Surgical Nutrition,
Ed. Charles W.Van Way, First ed. J.B.Lýppýncott Company Philadelphia, 1992;107-119.
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
Barendregt K, soeters PB, Allison SP.: Diagnosis of malnutrition. Screening and
assessment. in Basics in clinical nutrition, second edition Editor in chief Lubos Sobotka Galen,
2000 p: 29-36

David E Carney DE, Meguid MM : Current concepts in nutritional assessment Archives of
Surgery;2002; 137: 42-45
Methods of measuring body composition
Nachum Vaisman
Am of the lecture:
To give a comprehensive overview about the components of body composition and the different
methods available for their measurement.
Learning objectives:
1. To study the different components of body composition and the models of compartments.
2. To study and understand the specific methods of measurements, their advantages and
drawbacks.
3. To learn how these methods can help in clinical situations
Summary
Measurements of body composition are essential to the nutritionist as a tool for evaluating the
patient's nutritional status on admission and follow the efficacy of his nutritional intervention on
follow-up. Measurements can be made on different levels: atomic, molecular, cellular, tissue or the
whole body. In clinical settings, the most used methods include the whole body approach or the
tissue-system approach. The latter can be studied in a 2-compartment model or a more detailed one,
the 4-compartment approach. The two compartments include the body fat mass (FM) and the fatfree body mass (FFBM). The latter is almost identical to the lean body mass (LBM). The fourcompartment approach further breaks down the fat-free mass into three sub-compartments: body
cell, extra-cellular water and bone. The different methods of measurement are based on biochemical
and physiological characteristics. Some of the methods measure directly the specific component,
but others are derived from other measurements, based on specific physiological assumptions.
Understanding the background and the rationale behind a method can help in the interpretation of
the results. Underwater weighing or air displacement plethysmography can help in obtaining the
two compartments: FM and FFBM. MRI and quantitative CT can also measure FM directly.
Indirectly, FM can be derived from measurements of 2-4 sites of subcutaneous fat skin folds. FFM
and FM as well as the bone can be measured by the DXA (dual energy X-ray absorptiometry)
method which uses two levels of X-ray energy and separates the compartments based on the
different attenuation of the X-ray energy in a tissue–specific manner. Based on the assumption that
cell hydration is constant (73% of the cell) measurements of total body water and its two
components: extra cellular and intracellular, can be used to derive FM. Total body water can be
studied by isotopic labeling of water (HDO, THO, H2O18) or by the bioelectrical impedance method
(BEI). The different components of FFM can be derived
by direct and indirect measurements. Extracellular water can be measured by the dilution method
(bromide space) or by BEI, bone can be assessed directly by calcium neutron activation method or
indirectly by DXA and body cell mass can be directly assessed by whole body potassium and
nitrogen neutron activation, or indirectly by measuring intracellular water.
Muscle mass can be estimated by creatinine excretion or 3-methyl histidine excretion in the urine.
Choosing the proper method to study body composition depends on availability, the question asked
and the ability to interpret the results.
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References:
1.
Wang ZM, Pierson RN, Heymsfield SB. The five-level model: a new
approach to organizing body-composition research. Am J Clint Nutr
1992:56:19-28
2.
Goodpaster BH. Measuring body fat distribution and content in
humans. Curr Opin Clin Nutr Metab Care 2002:5; 481-487.
3 . Mazess RB, Barden HS, Bisek JP, Hanson J. Dual-energy x-ray
absorption for total-body and regional bone mineral and soft tissue
composition. Am J Clin Nutr 1990: 51; 1106-1112.
4.
Schoeller DA. Bioelectrical impedance analysis. What does it
measure? Ann NY Acad Sci 2000:904; 159-162.
Laboratory and balance-studies
Rémy Meier,
Aim of the lecture:
To know the benefits and limits of laboratory and balance-studies for nutritional assessments
Learning objectives:
- To be able to identify patients at risk for malnutrition, to use the appropriate laboratory test for
nutritional assessments and to know the strengths and limits of this test.
- To use an appropriate monitoring to assess the response to nutritional intervention.
Content:
A complete nutritional assessment consists of a combination of subjective and objective parameters,
but up to now, no single parameter has been shown to be useful in all patients. Most nutritional
parameters lack sensitivity and specificity; therefore, methods of identifying malnourished patients
are not entirely satisfactory. Laboratory testing is useful for assessment of the nutritional status and
monitoring of nutritional interventions. Several laboratory parameters (serum proteins, total
lymphocyte counts, vitamins and minerals) are used. Serum proteins have different half-life times.
Serum albumin is a good predictor for outcome and reflects disease severity. On the other hand, it is
a bad marker to assess nutritional status. Serum albumin can be used for long term control. To
assess short term changes, prealbumin or transferrin is more useful. Serum proteins have many
limitations. The serum concentrations of visceral proteins decline with overhydration and increase
with dehydration independent of nutritional status. Low serum albumin levels exacerbate ascites,
lower extremity edema, and gut edema because of depressed colloid oncotic pressure. Serum
transferrin is the less affected protein by other factors.
Immune function can be tested by lymphocyte counts and by cutaneous applied skin tests. In most
hospitalized patients, delayed hypersensitivity reactivity and total lymphocyte counts are not very
useful components of a nutrition assessment profile.
The somatic protein compartment can be evaluated by the creatinine height index (CHI). Creatinine
excretion correlates with lean body mass and body weight. The CHI is depended on urine creatinine
excretion. Renal insufficiency, meat consumption, physical activity, fever, infections and trauma
influence urine creatinine excretion.
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Nitrogen balanced studies are often used to assess protein catabolism. In non-stressed conditions,
urea composes 30-90% of total urea nitrogen. For usual clinical purposes, nitrogen balance
calculation done with urinary urea nitrogen instead of total urinary nitrogen is adequate. It has to be
considered that nitrogen excretion calculated from urinary urea nitrogen is affected by increased
stress, which can alter urea production and/or increase of non-urea nitrogen by-products. The
validity of nitrogen balance is affected by severe nitrogen retention disorders, accuracy of the 24hour-urine collection and completeness of protein or amino-acid intake data.
A simple assessment to assess catabolic states is also the urea production rate and the
urea/creatinine quotient.
Nutritional monitoring and reasons of response can be measured in vivo (by weight gain, Nbalance, complication rates) and in vitro measurements by plasma-serum concentration of proteins.
For identifying patients with pre-existing malnutrition or those at most risk, a combination with a
comprehensive nutritionally focus physical exam together with carefully selected objective
parameters provide the best information.
References:
1.
Hopkins B: Assessment of nutritional status. IN Nutrition Support Dietetics Core
Curriculum, 2nd ed, Gottschlich MM, Matarese LE, Shronts EP (eds). A.S.P.E.N., Silver
Spring, MD, 1993.
2.
Teasley-Strausburg K, Cerra FB, Lehmann S, et al: Nutrition/metabolic assessment. IN
Handbook for Nutrition Support, Strausburg KT, et al (eds). Harvey Whitney, Cincinnati, 1992.
3.
Teasley-Strausburg KM; Anderson JD: Assessment, prevalence and clinical significance of
malnutrition. IN Pharmacotherapy: A Pathophysiologic Approach, 2nd ed. DiPiro JT, et al (eds).
Appleton & Lange, Norwalk, CT, 1993.
4.
Daley BJ, Bistrian BR: Nutritional assessment. IN Nutrition in Critical Care, Zaloga GP
(ed). CV Mosby, St. Louis, 1994.
5.
Kopple JD: Uses and limitations of the balance technique. JPEN 11(5):173-179, 1987.
6.
Konstantinides FN: Nitrogen Balance Studies in Clinical Nutrition. Nutrition in Clinical
Practice, 7:231-238, 1992.
7.
Twomey P, Ziegler D, Rombeau J. Utility of skin testing in nutritional assessment: A critical
review. JPEN 6(1):50-58, 1982.
Food intake assessment
Osman Abbasoglu
Aim of the lecture
:
The aim of this session is to introduce various methods for the assessment of food intake and to
describe different components of food
Learning objectives
:
- To define food intake measurements
- To be able to assess nutritional status in respect to dietary intake
- To classify food contents
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Content of the lecture :
Food intake assessment estimates food intakes and is among the main tools for assessing nutritional
status. Food intake measurements are used not only for the determination of patient’s nutritional
status, but also characterization of the nutritional status of a population for monitoring and
surveillance. Assessment of dietary intake has considerable challenge and prone to significant error
and bias. Food balance sheets and household budget surveys are indirect methods of food
consumption studies Food records and dietary recalls measure food intake on specified period,
usually 1-7 days. Because of day to day variability, several days of records may be required to
estimate usual food intake. Food frequency questionnaires are developed to describe standardized
data on usual long-term diet.
The determination of the consumption of nutrients can be achieved either by analyzing the
foods consumed directly or by using food composition tables. Most food composition tables are
organized according to the classification of foods into food groups. Dietary reference intakes (DRI)
provide standards to serve as a goal for good nutrition.
Suggested readings:
1. Rutishauser IHE, Black AE. Measuring food intake. In: Introduction to Human Nutrition (Gibney
MJ, Vorster HH, Kok FJ, Eds.) p.225-249, Blackwell Publishing, 2002
2. Patterson RE, Pietinen P. Assessment of nutritional status in individuals and populations. In:
Public Health Nutrition (Gibney MJ, Margetts BM, Kearney JM, Arab L, Eds.) p. 66-82, Blackwell
Publishing, 2004
3. West CE, Schonfeldt HC. Food composition. In: Introduction to Human Nutrition (Gibney MJ,
Vorster HH, Kok FJ, Eds.) p.249-262, Blackwell Publishing, 2002
Overnutrition
Luboš Sobotka
The aim of lecture:
To explain diagnostic criteria, epidemiology and consequences of obesity and overnutrition
Learning objectives
- To be aware of the prevalence of overnutrition
- To understand the risk of chronic overfeeding
- To recognize the relationship of obesity to metabolic syndrome
- To know the influence of fat accumulation on insulin resistance
Content of the lecture
- Definition of obesity
- The prevalence of obesity
- Complications of obesity and insulin resistance
Overnutrition can be characterized as situation when energy intake is higher then energy
expenditure. Chronic overnutrition leads to storage of energy mainly as fat in adipose tissue. Fat is
probably also the principal macronutrient high intake of which is responsible for obesity
development.
Nowadays obesity is classified according to the BMI. Although obesity is defined as a BMI >
30, the health risks of increased body weight rise progressively when BMI exceeds 25. Morbid
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obesity (BMI >40) is a serious disease and patients rarely live longer than 60 years. Metabolic risk
of obesity can be predicted according to waist circumference. Moderate risk can be supposed if
waist circumference is more then 80 cm for men and 94 cm for men. Severe risk if it is more then
88 and 102 cm, respectively.
Overnutrition and obesity are important global health problems that continue to rise in many
“developed” countries. The prevalence of obesity had nearly trebled to 21% of women and 17% of
men by 1998 in the UK and estimates suggest that over 50% of women and about 66% of men are
either overweight or obese. In the majority of European countries the prevalence of obesity
increased by between 10 to 40% from the late 1980s to the late 1990s. The frequency of obesity is
greater in lower socioeconomic groups, especially after they moved to economically rich country.
Adipose tissue is not only a passive store of energy; it is also an active secretory tissue,
producing many hormones, cytokines, and other metabolically active substances that contribute to
development of the metabolic syndrome. Especially rezistin, angiotensinogen, PAI-1,
proinflammatory cytokines, acylation-stimulating protein, fibrinogen-angiopoetin-related protein
and metalothionein are main substances that can play a role in glucose intolerance, oxidative stress
and inflammatory reactions, which may contribute to the relationship between obesity and
cardiovascular disease. Moreover the release of fatty acids by lipolysis from adipose tissue is
increased in obese subjects. This can lead to hyperlidaemia, insulin resistance and toxic damage to
the beta cells of the pancreas.
Obesity contributes to the onset of many disabling chronic diseases (e.g. hypertension, coronary
heart disease, type 2 diabetes mellitus and some tumors) and to premature mortality. The incidence
of peri-operative complications is also higher in the obese, however this has been significantly
reduced by laparoscopic surgery. This is mainly due to respiratory failure, impairment in
fibrinolysis, hypercoagulable state, and decreased resistance to infections. Therefore prevention and
treatment of obesity should be obligatory part of health care.
Nutritional assessments questionnaires and formulas
Yitshal Berner,
Aim:
To have the capacity to choose questionnaire, and the knowledge about the most common
questionnaires.
Objectives:
1. To recognize the data components of questionnaire: dietary, habits, and medical history,
physical examination and anthropometrics and laboratory data.
2. To recognize what is the purpose of questionnaire: survey, guidelines, special research,
decisions making, etc.
3. To know about several running questionnaires.
4. To be able to choose questionnaire for specific purpose.
Content:
Questionnaires are in common use in the medical practice and in nutrition assessment as well as in
decisions making process. Every questionnaire has to pass validation to certain “Gold Standard”,
and reliability tests.
The data in questionnaire may be of different types: 1. Dietary data, either before analysis or
specific components after dietary analysis. 2. Anthropometrics data like height, weight, BMI, or
body composition.3 Laboratory results and special tests done. 4. Eating habits like timing of meals
and where they are taken. 5. General health questions. 6. Medical data like diagnoses, surgical
treatments and drugs.6. Demographic and socio-economic data.
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It is very important to evaluate the objective of the questionnaires. Many questionnaires are
designed as epidemiological surveys, and others as clinical tools for specific purposes, some are
designed for every person and some for specific populations, some are for the detection of
malnutrition while other concentrate on risk evaluation due to metabolic diseases as Diabetes,
hyperlipidemia and obesity.
Several questionnaires such as the ESPEN guidelines for detection of Hospital Malnutrition (1), the
MNA (2) the NSI (3), comprehensive review of the methods is attached (4) and several reprints of
important questionnaires are attached o the course program.
The main benefit of questionnaires are the standardization of data collections therefore their use is
very important for research mainly of multi-center and international type.
.
Conclusions:
Questionnaires are important tools in the nutritional assessment, but we have to know the purpose,
the data and the validation of each questionnaire before using it.
References:
1. Kondrup et al ESPEN Guidelines for Nutrition screening 2002. Clinical Nutrition
22:415,2003.
2. Guigoz Y, et al, Garry PJ. Assessing the nutritional status of the elderly: the mini nutritional
assessment as part of the geriatric assessment. Nutr Rev 1996;54:S59-S65.
3. White JV, Ham RJ, Lipschitz DA, Dwyer JT, Wellman NS. Consensus of the Nutrition
Screening Initiative: risk factors and indicators of poor nutritional status in older Americans.
J Am Diet Assoc 1991; 91: 783-7.
4. Y.N. Berner, Nutritioal Assessment, In E. Lebenthal Nutrition for Longevity.
IASA International Seminars Ltd. Jerusalem 2003. pp 250-266
Energy Balance
Nachum Vaisman
Aim of the lecture:
To give a comprehensive overview about the different components of energy metabolism, their
relative contribution and the methods to measure them.
Learning objectives:
1. To study the components of the energy balance equation.
2. To study the different components of daily energy expenditure
3. To understand the relationship between energy expenditure and body composition.
4. To learn how these methods can be used in clinical situations
Summary
Most of the biological organisms tend to maintain their condition, a process called: homeostasis.
From an energy point of view, this can be only maintained by conserving energy, or changing one
form of energy into another. The nutritional equation reflects the notion that during constant weight
the energy intake equals the energy expenditure. This is true when nutrients' absorption is not
impaired. Recent studies suggest that there are some situations where these are not kept and a
"calorie is not a calorie".
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Macronutrients' oxidation yields C02 and water, and during this process
heat and ATP are generated. Measuring O2 consumption or CO2 production can indicate, therefore,
what are the energetic needs of the individual and can help us in tailoring his proper diet. Measuring
oxygen consumption and CO2 production, as well as nitrogen excretion, can also enable us in
defining the contribution of each macronutrient to energy expenditure. Total daily energy
expenditure (TEE) consists of 3 main components: resting energy expenditure which consists of 6070% of TEE, the thermic effect of food ~10% and the rest is expended on activity. In children, extra
energy is needed for growth, especially during the first 2 years of life and during adolescence.
Resting energy expenditure is the largest component of TEE and the most affected by energy intake
and disease states. As resting energy expenditure is mainly produced by lean body mass, the proper
way to express REE is by expressing it per kg of LBM rather than by kg of body weight.
Energy expenditure can be studied by few means. When measuring daily oxygen consumption and
CO2 production (such as in a room calorimeter) TEE can be calculated. An alternative method for
measuring TEE is by the doubly- labeled water method. Field studies suggested that monitoring
heart rate can also be used to measure TEE. In practice, the most used method is accomplished by
indirect calorimetry, which is used to measure REE and TEF. This is done first thing in the morning
in a supine position after 10-12 hours of fasting. The combination of measuring REE and body
composition, concomitantly, along with energy intake and absorption, when needed, can help us
make the right nutrition support.
References:
1.
Lowell BB, Spiegelman BM. Towards a molecular understanding od
adaptive thermogenesis. (2000) Nature:404; 652-660
2.
Donahoo WT, Levine JA, Melanson EL. Variability in energy expendiyure and its
components. (2004) Curr Opin in Clin Nutr Metab Care 7; 599-605.
3 . Indirect calorimetry and nutritional problems in clinical practice (2001)
Acta Diabetol 38;1-5.
4
Ainslie PN, Reilly T, Westertrep KR. Estimating human energy
expenditure. (2003). Sports Med 33; 683-698.
Assessment of risk of malnutrition and under nutrition
Luboš Sobotka
The aim of lecture:
To explain the consequences of undernutrition in hospitalized patients in stress and non-stress
conditions
Learning objectives:
- To understand the difference between simple and stress starvation
- To know the risks of previous malnutrition for surgical stress and acute illness
- To be educated in functional consequences of malnutrition
Content of the lecture
- Reaction to the non-stress fasting
- Stress reaction and malnutrition
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Humans adapt well to starvation, using their reserve stores of carbohydrates, fat and protein, and
by reduction of energy expenditure protein conservation. This reaction depends on energy reserves,
duration of starvation and any additional stressful influences.
During non-stress conditions subjects with normal body composition can survive more than two
months. This leads to marasmic wasting. Glycogen stores are quickly exhausted and glucose is
derived from gluconeogenesis from precursor muscle amino acids and adipose tissue glycerol. After
period of adaptation glucose production is slowed by a decline in metabolic rate of 10–15% and by
reduction of glucose demand. Energy is supplied by an increased -oxidation of fatty acids and
increased production of ketone bodies in the liver. Albumin concentration is unchanged, although
plasma half-life proteins may be decreased. Consequences of long-term starvation are: anxiety,
depression, impaired muscle function, decrease in cardiac output, hypotension, circulatory failure
and reduction of renal function. Malnutrition impairs cell mediated immunity and resistance to
infection. Protein depletion decreases respiratory muscle strength and bronchopneumonia is
frequent consequence as result of hypoventilation, inability to cough effectively and impaired
resistance against infection. The mucosal cells atrophy with impaired absorption of lipids,
disaccharides and glucose is also a consequence of prolonged starvation. Starvation predisposes to
hypothermia and fever may be absent even with life-threatening infection.
In opposite, the stress starvation occurs when the individual is not only starved but also
subjected to the metabolic response to trauma, sepsis and critical illness. In this condition metabolic
reaction is mediated by catabolic hormones, insulin resistance, cytokines, eicosanoids, oxygen
radicals, and other local mediators. Metabolic rate increases, ketosis is minimal, and protein
catabolism accelerates as well as gluconeogenesis with subsequent hyperglycemia and glucose
intolerance. Salt and water retention leads to edema formation. This may result in a kwashiorkorlike state with edema and hypoalbuminaemia.
Patients with prior malnutrition who then develop acute illness have less reserve with which to
face that illness and do less well, with higher mortality, more complications and prolonged
recovery. If surgery is planned in these patients nutritional support improves physiological
functions and lessen surgical risk.
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