Tag: albumin

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Individual Nutrition assessment – an example chart note

What is health care? What is included in an individualized health care appointment?

The answer varies with the type of specialist you are seeing – and what they are allowed to do within their facilities’, or the individual’s insurance plans protocols.

My nutrition counseling experience was in prenatal/early childhood, and residential (nursing home) facilities.

Chart notes would be written for high risk clients when working in either role. Occasionally the nutrition assessment and recommendations note would be sent to the physician directly if very high risk.

As a preventive health focused prenatal/early childhood counselor, or for residential facility chart review (nutrition assessments of all nursing home residents considered high risk nutritionally, occasionally would include an in person visit with the resident to visually observe and ask further questions about their health and diet symptoms.

Patients typically do not see a chart note. They might be given the ‘Problem’ and ‘Assessment’ sections as an action list of recommendations on a simpler handout. The medical chart has a Care Plan section where recommendations for a daily change in care might be added – such as adding a high protein snack in the evening.

I would typically spend a half hour to an hour per client and writing a good note might take an additional 15 minutes. Current insurance standards have been set which limit physicians to 15 minutes per patient appointment – and only scheduling/discussing one symptom per appointment. That would make a differential diagnosis fairly impossible.

  • The entirety of a person’s symptoms – and what makes the problems worse, and what seems to improve things – is what provides clues to the underlying issues that may have led to the increased inflammation and/or decreased function.
  • Health is a balance of not too much inflammatory response -> autoimmune or allergies – or too little -> rampant infection and catching every cold.
  • Health is also a balance of enough nutrients and not too many toxins to cope with, whether from air, water, food, or touch, or from internal production of stress chemicals caused by emotional or physical stress.

Autoimmune issues are particularly challenging because many odd symptoms can occur, and more than one type of autoimmune antibody may be involved – not just one ‘autoimmune disease’ – several. Low vitamin D makes autoimmune issues more likely to occur, and low magnesium can make low vitamin D more likely – even with supplements of vitamin D.

Low magnesium also increases inflammation symptoms, pain, and anxiety, depression or anger and irritability.

A physician might look at my example note (below) and think: ‘but this is not my field‘ — exactly — please refer to the specialist – a registered dietitian or clinically trained nutritionist. Caution, there are many ‘nutrition certification’ programs online which are not equivalent to a college education, internship, and the equivalent of a lawyer’s Board Exam.

The client gave permission to share the write-up for educational purposes or maybe to help someone. Patients know that pain hurts, and that health is better. Too often I hear from physicians something like ~ ‘we don’t know what is causing this, … so the patient will probably die‘ – but it is regarding symptoms that likely involve nutrient deficiency.

Even sick patients need to eat or be fed and their nutrient needs are likely increased, or decreased, due to the illness, for a few specific nutrients affecting or being used in excess by the underlying issue. Telling a patient there is no hope is providing a nocebo – a negative expectation. Saying “I don’t know,” – when that is the true situation – would at least not be setting up a roadblock for the patient to seek further information or a second opinion.

If in reading my example chart note*, as a physician, you think, ‘but this is not my field‘ — exactly — you are correct – but it is the patient’s whole health that matters, not just symptoms that may be temporarily controllable by medications.

SOAPE note

The SOAPE chart note* below, is an extended version compared to what would be likely to be written in a patient chart. SOAPE note: Subjective, what the client said; Objective, what the clinician observed; Assessment; what the clinician believes may be underlying issues; Problem/Plan, recommendations being made by the clinician; Evaluation – an opinion statement about the likelihood of positive change, based on the overall attitude or motivation the client is presenting and social factors that may impact the client positively or negatively.

I included extra information that might be in a report to the client, with the education they might need to understand the reasoning for the recommendation, or how to proceed. Complex strategies can take several weeks of a class like setting possibly with cooking and tasting demonstrations. My web pages and posts try to provide self care guidance so a motivated learner could just try things and see if they help.

I added some additional info links for the version in this post, to pages or posts that provide some next step guidance, Gluten Free diet? what is that? The products on the market are not ideal suppliers of nutrients in my personal and professional opinion and learning how to bake gluten free can be healthier and less expensive for the nutrient value. My websites are my file cabinet of patient handouts, some of it.

While working as a public health nutrition counselor I did occasionally write a very thorough note for someone with a complicated case, and send it to the client’s physician on their or their child’s behalf.

Nutrient deficiencies can lead to death (niacin/pellagra example) – and can turn around dramatically very shortly after the nutrients and any cofactors are provided (nutrients are a team – refeed gradually and in balance).

Sometimes nutrition care is a life or death situation. Continue the nutrient deficiencies and deterioration can be rapid, and death can be the result. Niacin deficiency, pellagra, has a nickname for symptoms – the four D’s: “Pellagra defines systemic disease as resulting from a marked cellular deficiency of niacin. It is characterized by 4 “D’s”: diarrhea, dermatitis, dementia, and death.” (1) If there is severe lower leg rash and edema – suspect a B vitamin deficiency.

Nutrition assessment

Subjective:

  1. CoV like symptoms, mild, ~ early outbreak mid 2020, left a new problem, 2. swollen throat, reflux like pain/not quite reflux though, flair up of CoV symptoms again later when family had it 2021, again not too bad. 
  2. Swollen throat symptoms – has had labs showing autoimmune thyroid condition.
  3. Thyroid symptoms had improved a year or so earlier after stopping use of wheat/gluten and dairy. Recently started using ginger tea for the throat problem and it sooths. Hasn’t used long term, recent addition. 
  4. Reading about eosinophilic esophagitis did not sound like the problem. 
  5. Reading about histamine/MCAS symptoms did sound like it might be a problem. Tomato/salsa particularly, chicken causes congestion. Likes to drink orange juice.

Objective:

  1. Pale complection, may suggest magnesium deficiency/low vitamin D, low level anemia of chronic inflammation possibly.
  2. Throat visibly enlarged in pattern of enlarged thyroid gland 

Assessment: 

  1. CoV, even with mild symptoms, may have increased autoimmune antibodies, or created new types. Pale complection may suggest magnesium deficiency/low vitamin D, low level anemia of chronic inflammation possibly.
  2. Enlarged thyroid gland would be likely to cause difficulty swallowing at times, particularly if a food flair of the underlying autoimmune antibody sensitivity. (The thyroid gland presses inwards also and can narrow the throat significantly – *personal experience from also being an autoimmune thyroid patient, swallowing a large supplement can be very painful, and may feel stuck even.)
    1. Eosinophilic esophagitis might also be adding to swallowing symptoms if early stages, wouldn’t be causing as severe reflux symptoms as a more advanced case which is more likely to be what is described in articles about the problem. Food sensitivities are the most frequent cause and include gluten, dairy, eggs, and other common food sensitivity foods.
  3. Autoimmune thyroiditis can be a gluten molecular mimicry problem – the thyroid hormone chemically is similar to the gluten molecule. 
  4. Autoimmune antibodies to other food chemicals might also flair up an underlying autoimmune overactive eosinophile problem, white blood cells. Ginger contains a chemical similar to albumin and an egg sensitivity might be triggered by a sudden increase in use of ginger – or chicken – or eggs, or any animal product containing albumin. *also learned from personal experience – this can be a significant problem – I developed sensitivity to eggs and gradually realized I needed to exclude all sources of albumin or my symptoms would flair up again (non healing rash, not quite eczema – more wounds, lack of skin regrowth).
    1. An apparent ‘wheat/gluten’ sensitivity might be an albumin sensitivity, see one of my early posts with the information about plant albumin in wheat and ginger: Wheat is rich in albumin – so are ginger and egg whites.
  5. Histamine sensitivity seems a problem worth working on by decreasing trigger foods. Orange juice could be an additive problem food. The total load is part of the problem but even small amounts can set off the allergy cells that increase inflammatory cytokines and pain/inflammation signals – swollen, itchy, sore throat, dry eyes, but it can also effect mood when a more severe problem – extreme anxiety and fear, or out of control, hyper-excitable.

Problem:

  1. Elevated iron and symptoms of anemia of chronic inflammation may be a lingering CoV effect or of autoimmune conditions – it can be common to have several types of autoimmune antibodies also, and there has been cases of LongCovid where autoimmune antibodies were found. The spike lodges in a receptor and antibodies are made against the receptor, instead of against spike.. 
    1. Iron chelators may help mitigate chronic inflammation damage, restore energy level if that is a problem. The quercetin is one, continue regularly, opposite the niacin protocol if following that., or eat more of the good plant sources of a few, EGCG, pomegranate peel, green tea, oregano, olive leaf extract, there are many see the Iron chelator section of this Resources & Iron Chelators list. 
    2. Epsom salt soaks for a topical source of magnesium, help immune function, energy level, fluid balance. Continue if already using or start 1-3 times a week.
    3. Sunshine or Full spectrum light 20-30 minutes per day and or a moderate dose vitamin D3 ~ 600-1000 IU. 
    4. Avoid glyphosate residue. Consider supplementing with DMG, dimethylglycine, bulk powder, 1/2 spoonful once or twice a day in water or with a little juice and water. (too much juice is not really good for us).
  2. Thyroid problems in the modern world are likely related to excess fluoride and bromide and too little iodine. Cautiously increasing iodine and 200 mcg selenium may be helpful. Higher dose for one month can help the body to dump fluoride, bromide and chloride. When there is a lack of iodine the body will build molecules with the other halides, but then the thyroid hormone or other chemical won’t work right. Lab tests may show ‘normal’ levels of thyroid hormone but symptoms of hypothyroidism may still be present.
    1. In autoimmune conditions, when possible, it is essential to identify the trigger foods and strictly avoid them. It can take 6 months for antibodies to fade away, at which point symptoms should improve, but memory B cells still exist so even little tastes of the problem foods can set off a new 6 month batch of autoimmune antibodies that will attack the thyroid gland, or esophagus, or wherever else the problem point is located. 
    2. In this case eggs/chicken/ animal products/ ginger/ albumin /*hemp kernels too then/, may be part of the problem foods – 
    3. Elimination type diets that start with the least risky foods and gradually reintroduce things one at a time can be the best way to individualize what is the problem for you the individual. 
  3. Gluten was definitely identified as a part of the thyroid problem by removing, it already had helped to stop that. Dairy has a variety of allergens, and also would have albumin. Removing food triggers strictly, can help a swollen thyroid gland reduce in size – versus get more swollen when trigger foods are eaten.
    1. Gluten free baking recipes and tips for converting recipes: effectivecare.info – G8. Cookies & Bean Soup. -> and it mentions that increasing corn or corn flour instead, is not ideal either. Corn or gluten can increase zonulin which also increases leaky membranes in the gut or blood brain barrier, and more open membranes can increase risk of allergens entering undigested from the diet. See: What is Zonulin? (2)
    2. A quick mix recipe that can be used for pancakes or muffins, a post: Pancakes in a Jiffy – Quick Bread Mix.
  4. Eosinophilic esophagitis may be related to food sensitivities, so as food elimination is attempted it would also be helpful to pay attention to the swallowing symptoms to see if change occurs other than the swollen pressure feeling of the enlarged thyroid gland.
    1. “Research shows a strong connection between food allergies and eosinophilic esophagitis (EOE). These six foods are most commonly associated with this allergic response: dairy, wheat, soy, eggs, nuts, and seafood/shellfish. Unfortunately, there is no accurate test to identify food allergies* connected with EOE.” (3) 
    2. *The food sensitivity is not the same type as tested for people who get hives to peanut butter or eggs or are allergic to bee stings. It is food sensitivity that activates white blood cells though, called eosinophils. 
    3. During normal function eosinophils fight parasites for us. So …. Maybe they are doing something in ‘autoimmune disease’ that involves their normal function too fighting an unidentified parasite – or they are responding to chemicals of the six foods listed above in an allergy-like way. 
    4. Asthma and allergies involve increased eosinophil activity, which can lead to inflammation symptoms and tissue damage: “Eosinophils can consume foreign substances. For example, they fight substances related to parasitic infection that have been flagged for destruction by your immune system. Regulating inflammation. Eosinophils help promote inflammation, which plays a beneficial role in isolating and controlling a disease site.” […] “…eosinophils play a key role in the symptoms of asthma and allergies, such as hay fever. Other immune system disorders also can contribute to ongoing (chronic) inflammation.” (4) 
  5. Eliminating common histamine problem foods may help anxiety and inflammatory symptoms. Orange juice, tomatoes, fermented foods, or older leftovers, cranberries, others, it is a lengthy list but can make a huge difference *personal issue for me also.
    1. More info on page MCAS/Histamine, jenniferdepew.com: MCAS/HIstamine.
    2. Summary of foods to avoid, or a few helpful in an over-reaction: Histamine Food Lists. it is a document (6)

Evaluation:

Client seems motivated and capable of making positive changes for improving health, cheerful and confident amid a complex set of problems, and has support of family.

So does my disclaimer make more sense now?

  • Disclaimer: This information is provided for educational purposes within the guidelines of fair use. While I am a Registered Dietitian this information is not intended to provide individual health guidance. Please see a health professional for individual health care purposes.

My professional and personal expectations of individualized health care guidance does not include a 15 minute appointment limited to discussing one symptom. In seeking a health care provider I recommend searching for ‘functional health’ or possibly holistic but that is less precisely used than ‘functional’. The orthomolecular approach is also whole body and restoring function oriented.

*am I taking clients? I am working in that direction but I am still in initial stages of having a system set up.

Change is easiest by just practicing the desired habit and the more often it is remembered, practiced, then the more that brain pathway will be strengthened and the old one is gradually deactivated, becomes harder for the nerve cells to fire instead of being an automatic habit like happens without even thinking consciously – to change that ingrained of a habit takes substituting a new pattern rather than trying to ‘attack’ with ‘will power’. Work with nature and it will work with you. Attack and it tends to have an undesired ripple effect.

Pain hurts, health is better.

We all die, the question is quality of life while living – and enjoying that life while living.

Namaste – the soul in me, sees the soul in you.

We are all children, under the care of Mother Nature and Father Sun.

Where there is light there is life, and there is hope.

Reference List

  1. Hegyi J, Schwartz RA, Hegyi V. Pellagra: dermatitis, dementia, and diarrhea. Int J Dermatol. 2004 Jan;43(1):1-5. doi: 10.1111/j.1365-4632.2004.01959.x. PMID: 14693013. https://pubmed.ncbi.nlm.nih.gov/14693013/
  2. What is Zonulin? https://www.creative-diagnostics.com/blog/index.php/what-is-zonulin/
  3. 6 Food Elimination Eosinophilic Esophagitis, oregonclinic.com, https://www.oregonclinic.com/6-Food-Elimination-Eosinophilic-Esophagitis-EOE 
  4. Eosinophilia, symptoms, mayoclinic.com, https://www.mayoclinic.org/symptoms/eosinophilia/basics/causes/sym-20050752

Documents, Posts & Pages

  1. Wheat is rich in albumin – so are ginger and egg whites, post transcendingsquare.com
  2. Resources & Iron Chelators list, document https://docs.google.com/document/d/1XiwJBPoFUnUTQKcRAW_8NMriQMt8b31zjeTY4zV0wJo/edit?usp=sharing
  3. effectivecare.info – G8. Cookies & Bean Soup, webpage
  4. Pancakes in a Jiffy – Quick Bread Mix. post transcendingsquare.com
  5. MCAS/Histamine. webpage, jenniferdepew.com
  6. Histamine Food Lists. document, https://docs.google.com/document/d/17iz9lsJyGqIUUjF0p-totXp4R2GhgRi2Na4gYueisTM/edit?usp=sharing
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Calciphylaxis, molecular mimicry and egg white albumin; an experiment, n = 1

Calciphylaxis is a rare type of wound that is associated with hyperparathyroidism and is most commonly seen in patients who are receiving kidney dialysis due to end stage renal disease. The condition is also associated with an eight times increased risk of morbidity (death) compared to patients who don’t have calciphylaxis.

The term calciphylaxis came to my attention this year when I found out that I had an elevated parathyroid hormone level. See the following posts for more information about calciphylaxis and about other symptoms associated with elevated parathyroid hormone:

  1. Secondary hyperparathyroidism, calcium deficiency and irritability, 
  2. Elevated parathyroid hormone (PTH) and 1-25-D, calcium deficiency and calciphylaxis, ‘Calciphylaxis is more of a risk with end stage renal disease but it has also been found in people who had normal vitamin D levels and normal kidney health. And “high dose vitamin D administration is capable of inducing STC (soft tissue calcification) and calciphylaxis in murine models. [56, 57] In an attempt to reestablish normal calcium-phosphate homeostasis, ESRD patients receive vitamin D analogs that could theoretically increase their risk of calciphylaxis if hyperphosphatemia and hypercalcemia ensued. [58, 59]” [3]

    “Experimental sensitizing events and agents included nephrectomy and exposure to parathyroid hormone (PTH) and vitamin D. Substances used as challengers included egg albumin and metallic salts. Calciphylaxis was the end result.4  – from a 1962 study, abstract is free. [4.5]’

  3. Secondary hyperparathyroidism and calciphylaxis symptoms; an update with lab values, 
  4. Calciphylaxis may be caused by several different nutrient issues, 

Antibodies against chemicals that are a normal part of the human body can develop in autoimmune disease. The term molecular mimicry refers to the autoimmune antibodies that may be manufactured by overactive white blood cells in response to a large foreign protein allergens that may have made it through ‘leaky’ intestinal walls into the blood stream.  See: Robert S. Fujinami, et. al., Molecular Mimicry, Bystander Activation, or Viral Persistence: Infections and Autoimmune Disease, Clin Microbiol Rev. 2006 Jan; 19(1): 80–94.

To skip to the point, egg white albumin is very similar to the albumin found in human blood. It is an essential protein within plasma and it helps maintain fluid balance between the blood plasma and extracellular fluid (too much extracellular fluid would be noticeable as edema – puffy ankles from excess fluid collecting outside of the cells and blood vessels.

After finding the research about egg white albumin on September 24, I eliminated egg white from my diet. My symptoms did get better fairly rapidly but I had tried a few strategies at the same time so it wasn’t clear whether stopping egg white had been necessary for the symptoms to improve or whether the other strategies I had tried may have been adequate on their own — so after feeling better for a couple weeks I decided to retry egg white to see if eliminating them had been an unnecessary strategy. Sadly I found that the day after trying egg white albumin again (in the form of baked chocolate chip cookies) my skin sores returned. I stopped eating egg white again. The sores aren’t as bad as they had been in September but calciphylaxis sores are termed necrotic wounds and necrosis means death and dead tissue in wounds can lead to gangrene and septic bloodsteam infections.

Open sores with oozing plasma that sticks to fabric is unpleasant and painful as well as being associated with an eight times increased risk of morbidity (which means death of the patient).

So I don’t have proof that my body set up autoimmune antibodies to albumin but I would rather stop eating egg white than continue having oozing sores – that is my choice, it is my body and I should have a right to take care of it to the best of my own ability rather than having to follow mainstream medical advice about a condition that is not well understood but is associated with an increased risk of death.

For more information about albumin antibodies and autoimmune disease see:

  • Rodríguez-Juan C, et. al., Increased levels of bovine serum albumin antibodies in patients with type 1 diabetes and celiac disease-related antibodies., J Pediatr Gastroenterol Nutr. 2003 Aug;37(2):132-5.
  • Excerpt from Abstract: “Although 46% of patients with autoimmune thyroiditis had positive results, the level detected (22.1 +/- 8.7 AU) was significantly lower than that recorded in patients with type 1 diabetes who had celiac disease antibodies (P = 0.04) and celiac patients (P = 0.04). Healthy volunteers showed no antibodies against bovine serum albumin.”  “Thirty-one percent of patients with diabetes yielded a positive result…” End stage renal disease is actually a significant risk for people with autoimmune Type 1 Diabetes because diabetes can cause an increased load on the kidneys from excess blood sugar and increased leaking of protein into the urine. Thirty-one percent of them might benefit from avoiding beef (bovine) or egg white albumin – but more research would probably be necessary before an ‘evidence-based’ recommendation could be made – except Rodriquez- Juan C, et al, did get a nice start on the project.

 

/Disclosure: This information is provided for educational purposes within the guidelines of fair use. While I am a Registered Dietitian this information is not intended to provide individual health guidance. Please see a health professional for individual health care purposes./

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Alp Luachra, an old name for edematous malnutrition

Alp Luachra is a Celtic fairy with a pet newt. It was considered dangerous to fall asleep near a stream. Alp Luachra might climb into the victim’s mouth along with his pet newt. They would live in the stomach and gobble up nutrients while the rest of the accursed person shriveled away. No matter how much the victim would eat they would eventually starve – because Alp Luachra leeches all the nutrition away. I learned of him from my new book, Tarot of the Celtic Fairies. The picture on the Tarot card does resemble edematous malnutrition with a very round belly and thin, starved looking arms and legs. Maybe it does exist outside of the tropics. (The 9 of Cauldrons card from  Tarot of the Celtic Fairies 14)

Kwashiorkor, (that rare tropical form of malnutrition in toddlers weaned from breast feeding too rapidly, and/or from lack of introduction of insects to the diet at the appropriate stage), has been in the news. An insurance billing watch dog group found an increased use of the diagnosis code for kwashiorkor/malnutrition in a group of California hospitals. Prime Healthcare Service’s response to the allegations that a diagnosis of malnutrition was used to increase reimbursement states that the facts were distorted in order to mislead the public and gain concessions. It continues that the “relevant (i.e., where the diagnosis affected reimbursement) malnutrition rate at all Prime Healthcare hospitals was 3.6%,which is much less than the rates referenced in the article. For example, their relevant malnutrition rate at Huntington Beach hospital was 5.3% rather than the 39% reported by California Watch.”

That seems reasonable to me. It continues to review the disturbing prevalence of malnutrition and their screening program that Prime Healthcare hospitals use for improving patient care and decreasing morbidity and mortality rates a nutritional screening for their elderly patients is part of their routine care.

Published studies estimate that up to 15% of ambulatory elderly patients, up to 44% of homebound elderly patients, up to 65% of hospitalized elderly patients, and up to 85% of nursing home patients are malnourished. Hajjar, R.R., Kamel, H.K., Denson, K., Malnutrition In Aging, The Internet Journal of Geriatrics and Gerontology, Volume 1, Number 1 (2004); Chen, C.C-H, Schilling, L.S., Lyder, C.H., A Concept Analysis of Malnutrition In The Elderly, Journal of Advanced Nursing, Volume 36(1) (2001).

** Prime Healthcare sounds like a good place for dietitians to work. A nutrition screening by a Registered Dietitian is vital for quality preventative health care. A multidisciplinary team allows a thorough assessment from multiple viewpoints – a stethoscope or a microscope or a little Celtic sparkle – who knows the health solutions that teamwork can bring. However, I was just reading about albumin on RD411, an information website, today [16]. I learned that low albumin is not considered useful to tell if a patient is malnourished because it is easily influenced by many factors besides dietary protein intake. However, at the same time I learn that it is associated with increased mortality and morbidity – so I am left to assume that  I needn’t consider the elderly person with an albumin of 7 or 8 as ‘malnourished’ but just to consider them at increased risk of morbidity and mortality instead. The recommendation is to continue dietary calculations as normal, but instead of pouring another Health Shake to add to the malabsorbtion mess I would rather consider what is causing the shift in fluid and what might be better absorbed than what we already have been trying.

In research by Yi-Chia Huang et al, the elderly Taiwanese population had an intake range of 573.9 to 3191.9 kcal/day and no association between functional status and intake could be made.  Intake of at least 55 grams protein per day was associated with better function but higher levels of protein intake again could not be correlated to improved status. [7] In cases of malabsorption we can pour in 3000 calories per day and there will be no guarantee that it will be more helpful than 573. It would probably be more harmful than low intake. Anything that passes through the body has to be brought into safe balance with the chemical needs of the intestinal lining. Magnesium is a buffer that is taken from the bones to “fix” over acidic conditions. High protein, dairy and sugar intakes add to acidic conditions and coffee, carbonated beverages, black tea, and fruit juices can be very acidic. For strong bones try choosing an herbal or green tea and pass on the extra large glass of pop or milk and the triple shot of alcohol too probably.

There is controversy over using just the albumin level for a diagnosis of malnutrition and it is true that short term edema – puffiness – will cause low albumin levels while puffy. With less fluid in the blood and more fluid in the spaces between cells and organs there will be less albumin. It is a blood protein that acts a little like a sponge to attract and keep fluid around it but where the fluid goes it is also attracted to follow. Circular paths are the way of nature. The albumin level that remains low for months – rather than during an acute week of an illness – I would strongly consider the possibility that an underlying malnutrition problem is the cause of puffiness and low albumin, the reasons for the initial malnutrition can vary but once the poor absorption starts the problems picks up pace and the body deteriorates from feeding on itself – there isn’t a newt but there is a brain, heart and lungs as long as the fingers, toes and remaining peripherals hold out (reminder Buerger’s vasculitis disease [15]).

One lab test can be supported by other labs and observed signs and symptoms of health or weakness. Several studies have found that assessing frailty factors seems more correlated with a variety of quality of life factors and improved surgical recovery rates than BMI. More than 3 of 5 of the following – unintentional weight loss, weakness, self-reported poor energy, slow walking speed, and low physical activity  was found associated with risks of falls and fractures. Hand grip strength, and calf muscle to fat area, mid arm circumference, sarcopenia were mentioned as measurements of improved muscle mass with improved health status. Sit ups and leg lifts or just a walk in the woods – better muscle mass is associated with longer life.

Based on the sensitivity of the autoimmune gut and my review of kwashiorkor research, I would surmise that a gluten free, lactose free, low calcium to magnesium ratio with an increase in glucosamine and other essential sugars (super starches) and plenty of B vitamins, C, A, zinc, selenium might help the catabolic patient with edema. We need to provide building blocks that readily make a strong glycocalcyx to reduce the leakiness of the intestinal lining.

I am glad that Prime Healthcare has had to stand up for malnourished patient’s rights – the right to a diagnosis that is accurate. An albumin of 7 or 8 is tragic and just because it is from excessive dilution due to malabsorption/mal-retention and not due to lack of protein in the diet – doesn’t mean it isn’t leading to cell starvation. Just because we don’t quite understand edematous malnutrition and don’t seem to know how to stop it, doesn’t mean that it doesn’t exist and isn’t killing people in a very costly and agonizingly slow way.

Names matter and the tropics and kwashiorkor is simply where the problem was studied most. Edematous malnutrition is a better name for the condition in my opinion than protein calorie malnutrition. Over the long term edema means that the cells aren’t being well fed or well detoxified. During edema the movement of fluid is reduced and the movement of nutrients and toxins is slowed. Over the long term edema leads to dysfunction and malnourishment. If the fluid in our toilets backed up regularly we would expect the plumber to repair it not just measure the dysfunction. Puffy abdomen and ankles = overflowing waste = better call a doctor on the Prime Healthcare team in case malnutrition is involved (and remember to ask for a referral to a Registered Dietitian); maybe repair is still in the future but recognition is at least a first step.

Kwashiorkor occurs on the same diet as marasmus malnutrition but the children have different metabolic reactions. Recent infection may be associated with the kwashiorkor susceptible population. Their intestinal lining lacked glucosamine and excess fluid movement both directions was the result. An enzyme deficiency for the conversion of glucose or galactose into glucosamine seemed to be a significant difference between the two groups of children and aldosterone levels were also abnormal in the kwashiorkor children but not the maramus group. Edematous malnutrition exists outside of the tropics.
Glucosamine supplements may be crucial for heart disease and other leaky membrane problems (dementia). Zinc and selenium are low in heart disease and B6 and all of the B vitamins are essential for cell growth and energy demands. Vitamin C is also depleted rapidly. Our “health supplement shakes” and complete feeding formulas are not based on ratios that the critically ill can tolerate – they are more harmful than helpful. We need research and development of an isotonic formula with high levels of beneficial nutrients and low levels of a few things that add to the body burden .

In the meantime more magnesium, B complex, zinc, selenium, iodine, glucosamine, taurine, vitamin C, and beta carotene rich dark green and deep orange fruit and vegetables may be helpful to the chronically ill and obese. Mushrooms, aloe vera, fenugreek, slippery elm powder and ginger also have essential sugars – super fiber for building a strong glycocalyx. The intestinal lining is an organ that protects and nourishes our bodies for miles – literally – do we want junk food littering the way or a strong yet fluid, free-form matrix of super starches, trace mineral ions lighting up the place and plenty of strong white blood cells patrolling for trouble.  Cancer wouldn’t stand a chance – or at least reduced chance.

***11-7-11 BTW I figured out what’s happening with the leaky membrane problem – its complicated – call me or read the [bazillion words, “Cantaloupe, listeria, and sea squirts, oh my,” Oct. 5, 2011]

__________________________________________________________________________

 /Disclosure: This information is provided for educational purposes within the guidelines of fair use. While I am a Registered Dietitian this information is not intended to provide individual health guidance. Please see a health professional for individual health care purposes./
  1. Olubukola O. Nafiu et al., “The Association of Body Mass Index to Postoperative Outcomes in Elderly Vascular Surgery Patients: A Reverse J-Curve Phenomenon,” Anesthesia & Analgesia 112, no. 1 (January 1, 2011): 23 -29.
  2. Ian M Chapman, “Obesity paradox during aging,” Interdisciplinary Topics in Gerontology 37 (2010): 20-36.
  3. S L Miller and R R Wolfe, “The danger of weight loss in the elderly,” The Journal of Nutrition, Health & Aging 12, no. 7 (September 2008): 487-491.
  4. Ian Janssen, “Morbidity and mortality risk associated with an overweight BMI in older men and women,” Obesity (Silver Spring, Md.) 15, no. 7 (July 2007): 1827-1840.
  5. Kristine E. Ensrud et al., “Frailty and Risk of Falls, Fracture, and Mortality in Older Women: The Study of Osteoporotic Fractures,” The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 62, no. 7 (July 1, 2007): 744 -751.
  6. Meei-Fang Lou et al., “Nutritional status and health outcomes for older people with dementia living in institutions,” Journal of Advanced Nursing 60, no. 5 (December 2007): 470-477.
  7. Yi-Chia Huang et al., “Nutritional Status of Functionally Dependent and Nonfunctionally Dependent Elderly in Taiwan,” J Am Coll Nutr 20, no. 2 (April 1, 2001): 135-142.  (free article)
  8. Matteo Cesari et al., “Frailty syndrome and skeletal muscle: results from the Invecchiare in Chianti study,” The American journal of clinical nutrition 83, no. 5 (May 2006): 1142-1148.  (free article)
  9. H K Vincent, K R Vincent, and K M Lamb, “Obesity and mobility disability in the older adult,” Obesity Reviews: An Official Journal of the International Association for the Study of Obesity 11, no. 8 (August 2010): 568-579.
  10. Heppenstall, et al, “Frailty: dominos or deliberation?,” N Z Med J. 2009 Jul 24;122(1299):42-53. http://www.nzma.org.nz/journal/122-1299/3710/.
  11. Fred Chau-Yang Ko, “The clinical care of frail, older adults,” Clinics in Geriatric Medicine 27, no. 1 (February 2011): 89-100.
  12. Stephane M Schneider et al., “Lack of adaptation to severe malnutrition in elderly patients,” Clinical Nutrition (Edinburgh, Scotland) 21, no. 6 (December 2002): 499-504.
  13. Lilian Liang et al., “Nutritional issues in older adults with wounds in a clinical setting” 1: 63-71.
  14. McElroy, Mark, Tarot of the Celtic Fairies, artwork by Eldar Minibaev, (2010, Lo Scarabeo, Via Cigna 110 – 10155 – Torino- Italy _www.loscarabeo.com_ (I hope this will be viewed as a brief extract and recommendation rather than copyright infringement.  I find Tarot cards a meditative cognitive therapy aid – solitaire for the brain.)
  15. http://www.hopkinsvasculitis.org/types-vasculitis/buergers-disease/ ***I discussed it in my article Vasculitis – Withering from Within.The main cause of this type is smoking and the best treatment is to quit smoking. Smoking depletes oxygen and antioxidants and magnesium – malnourishment from within – second best to quitting smoking would be of course to replenish with extra vitamin C and magnesium supplements and foods and some oxygen would help also vitamin A foods – supplements have not been helpful but the food has helped . . . carrots, peaches, sweet potatoes, tomatoes, broccoli and V8, mangos, apricots and cantalope.
  16. http://www.rd411.com/index.php?option=com_content&view=article&id=393:albumin-as-an-indicator-of-nutritional-status&catid=105:professional-refreshers&Itemid=400
  17. see my previous blogs Angelina please don’t risk the knife, and We are what we eat, for more Bibliography on kwashiorkor, insects and perimenopause.
  18. see my previous blogs on the glycocalyx and Electrolytes R Us, for more on leaky membranes and hydration.
  19. http://www.highbeam.com/doc/1G1-250812435.html . “Prime Healthcare Services Review of State Health Data Confirms Normal Malnutrition Rates Among Its Medicare Patients; Recent Studies Debunked.(Clinical report).” PR Newswire. PR Newswire Association LLC. 2011. HighBeam Research. 9 Apr. 2011 http://www.highbeam.com.

From a different list of reading:
7. Yi-Chia Huang et al., “Nutritional Status of Functionally Dependent and Nonfunctionally Dependent Elderly in Taiwan,” J Am Coll Nutr 20, no. 2 (April 1, 2001): 135-142.  (free article)

Excerpt from Conclusions section:
“There were approximately 36% of functionally dependent subjects who consumed energy less than 75% of the Taiwan RDNA in our study. The elderly with functional dependence might have more difficulties in accessing food. However, we could not find an association between energy intake and functional status. This might be due to large variations of energy intake among individuals ranging from 573.9 to 3191.9 kcal/day.
Consistent with Payette and Gray-Donald [24], the elderly had sufficient mean protein intake, but these authors’ association between protein intake and serum albumin concentration was not found. Morgan et al. [6], however, indicated a positive relationship between protein intake and serum albumin concentrations. It is worth noting that the association was valid only up to protein intake of 55 g/day. Since our subjects had a varied protein intake ranging from 23 g/day to 122 g/day and half of the subjects had a protein intake .55 g/day, the dietary protein intake might no longer have an effect on serum albumin concentration. Another possibility was that chronic conditions play a determinant role in affecting the albumin concentration.”

***Note on vitamin D – The chronically ill may have depressed 25-D levels because they have elevated 1,25 D levels resulting in more than enough of the active hormone for preventing fractures even though the vitamin level seems insufficient for the average person.

The enzyme to activate the vitamin to the steroidal hormone is made by white blood cells as part of the stress/inflammation response and in some cancer cell strains. An active D level above 45 means the bones are losing calcium stores. My five year 1,25-D average, while actively avoiding vitamin D foods, supplements and much time in the sun, was 59 pg/ml and my five year average 25-D was 20 ng/ml. The range was 51-71 pg/ml, 1-25-D and 8.0-26.7 ng/ml for 25D. Ex: 3-31-2009 25-D of 9.0 and 1-25D of 53 pg/ml. If I spend a day on the beach I am hurting two days later from the calcium that is drawn out of the bones – muscle spasms, fatigue and irritability symptoms primarily for me but ringing in the ears and a twitching eyelid have been reduced with magnesium. B vitamins and zinc tend to be involved to – magnesium rich foods would provide those as well as iron and iodine only if it was grown in iodine rich soil.

Kwashiorkor Bibliography

  1. http://www.ajcn.org/content/89/2/592.long ***Reduced production of sulfated glycosaminoglycans occurs in Zambian  children with kwashiorkor but not marasmus also good –
  2.  http://www.icmr.nic.in/ijmr/2009/November/1128.pdf  Tahmeed Ahmed, Sabuktagin Rahman and Alejandro Cravioto, Oedematous malnutrition,  Indian J Med Res 130, November 2009, pp 651-654
  3.  http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.htmlWilliams, L., Jewett, C., and Doi, S. K., Hospital chain, under scrutiny, reports rare illness (The Press Enterprise Local News)
  4. http://www.pe.com/localnews/opinion/editorials/stories/PE_OpEd_Opinion_D_op_27_ed_primehealth.1816fbc.html  Shady billing? (The Press Enterprise)
  5. http://www.sacbee.com/2011/02/20/v-print/3414850/medicare-billed-for-exotic-illness.html
  6. “Prime Healthcare Should Be Denied New Hospital Licenses Until Federal, State Investigations into Extraordinarily High Septicemia, Malnutrition Rates and Risk to Patients are Complete.” Business Wire. Business Wire. 2011. HighBeam Research.
  7. http://online.wsj.com/article/SB10001424052748703293204576106072340020728.html  Marcel Dicke, Arnold Van Huis are professors of entomology at Wageningen University in the Netherlands.  (2-19-11, The Wall Street Journal, pC3)  “The Six-Legged Meat of the Future“
  8. http://onlinelibrary.wiley.com/doi/10.1111/j.1525-139X.2010.00705.x/abstractEffect of Diabetes Mellitus on Protein–Energy Wasting and Protein Wasting in End-Stage Renal Disease, Nazanin Noori1, Joel D. Kopple1,2Article first  published online:13 APR 2010DOI: 10.1111/j.1525-139X.2010.00705.x
  9. http://www.ncbi.nlm.nih.gov/pubmed/19121473  Semin Nephrol. 2009 Jan;29(1):39-49. Causes and prevention of protein-energy wasting in chronic kidney failure. Dukkipati R, Kopple JD. Division of Nephrology and Hypertension, Los Angeles Biomedical  Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90509, USA.
  10. http://www.ncbi.nlm.nih.gov/pubmed/19121477 Semin Nephrol. 2009 Jan;29(1):75-84. Nutrition support for the chronically wasted or acutely catabolic chronic kidney disease patient.Ikizler  TA.Department of Medicine, Division of Nephrology, Vanderbilt University School of  Medicine,Nashville, TN 37232-2372, USA.
11. http://www.ncbi.nlm.nih.gov/pubmed/16129200Am J Kidney Dis. 2005 Sep;46(3):387-405. Multinutrient oral  supplements and tube feeding in maintenance dialysis: a systematic review and meta-  analysis. StrattonRJ, Bircher G, Fouque D, Stenvinkel P, de Mutsert R, Engfer M, Elia  M.Instituteof Human Nutrition, University of Southampton, UK.

12.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2891019/?tool=pubmed New Insights into the Role of Anabolic Interventions in Dialysis Patients with Protein Energy Wasting Jie Dong and T. Alp Ikizler1 Curr Opin Nephrol Hypertens. Curr Opin Nephrol Hypertens. 2009 November; 18(6): 469–475.doi: 10.1097/MNH.0b013e3283 31489d.

 “Economic Implications of Nutritional interventions It is also important to assess the impact of nutritional supplements not only in terms of changes in nutritional parameters, but to extrapolate these observations to potential improvements in hospitalization, mortality, and cost-effectiveness. In a recent study, Lacson et al showed that a hypothetical increase in serum albumin concentration in the order of 2 g/L in 50%  of the United States dialysis population would be associated with  projections of approximately 1400 lives saved, approximately 6000 hospitalizations  averted, and approximately $36 million in Medicare cost savings resulting  from a reduction of approximately 20,000 hospital days over one year[68]. This is a reasonable estimation since 2 g/L increase in serum albumin is the average improvement reported in most nutritional intervention studies.”

***The above paper is suggesting that giving them growth hormones  and other anabolic steroids along with protein will help them to stop catabolizing and start building albumin. They have had success with the strategy, but wouldn’t magnesium plus protein (ideally combined within the same magnesium foods) be cheaper than hormones and protein?