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D C Heimburger

Publications and source records attributed to D C Heimburger.

53 records · Page 3Linked to original sources
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Observations on the practice of clinical nutrition in hospitals in China.

Observations and interaction with physicians and surgeons in four Chinese medical institutions visited during 1983 are discussed in three broad areas: teaching activities and discussions comparing modern Western theory and practice in clinical nutrition with that in China; clinical rounds involving discussion of the nutritional problems of patients with a variety of diseases; a survey of hospital nutrition support practices in China. Difficulties in auditing the prevalence of hospital-associated malnutrition in these hospitals are discussed. Controlled, independent observations are required to estimate the incidence of hospital-associated malnutrition in China. While clinical nutrition has received little attention in medical training in China, the Chinese are eager for more educational input.

China↗
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Guidelines for evaluating and categorizing enteral feeding formulas according to therapeutic equivalence.

Because of the current rapid proliferation of commercially prepared formulas for use in supporting the nutritional status of patients, choosing among them is becoming progressively more difficult. There has been no unified discussion in the literature to date to help the clinician distinguish the important parameters of enteral feeding formula composition from the unimportant ones. Herein we stratify these parameters into three categories of relative importance, and classify the currently available formulas into categories of therapeutic equivalence. Together, the stratified parameters and the classification scheme may be used to evaluate new products in the future and establish a hospital enteral feeding formulary, which can simplify the clinician's choice of formulas and decrease patient costs.

Costs and Cost Analysis↗
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The role of protein in nutrition, with particular reference to the composition and use of enteral feeding formulas. A consensus report.

In its proposed classification scheme for reimbursement for enteral feeding formulas, the United States Health Care Financing Administration (HCFA) has neglected to consider the importance of making available formulas of varying protein content. In responding to HCFA's proposal, this consensus report reviews information currently available regarding different protein requirements in healthy, ill, and undernourished adults and elderly individuals. HCFA's reimbursement guidelines should reflect sound medical and nutritional practice rather than influencing it adversely, which its original proposal could do. Clinicians should have at their disposal enteral feeding formulas of varying protein/calorie ratios, especially since the following groups often have higher than average protein requirements relative to calorie requirements: the elderly, individuals with physiologic stress such as infection and injury, and patients with protein-calorie undernutrition.

Adult↗
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Metabolic complications of total parenteral nutrition: effects of a nutrition support service.

BACKGROUND: The effectiveness of Nutrition Support Services in optimizing parenteral nutrition has not been evaluated since the 1980s. METHODS: We prospectively monitored medical and surgical patients on total parenteral nutrition (TPN) in a university hospital who did not receive Nutrition Support Service recommendations to compare the incidence of metabolic complications in 1979 (group 1, n = 100) with that in 1992 (group 2, n = 106). The Service provided automatic recommendations on a subsequent group of medical service patients (group 3, n = 128) and compared them with the patients in group 2 who were on the medical service (group 2B, n = 29). RESULTS: Statistically significant changes between 1979 and 1992 included a decline in the incidence of hyperglycemia from 47% to 22% and in hypokalemia from 12% to 3% of surgical patients and an increase in hypomagnesemia from 0% to 23% of surgical patients and from 2% to 14% of medical patients. The incidence of hypophosphatemia remained > 20% in both medical and surgical patients. Within 1992, the addition of automatic recommendations had little impact on metabolic abnormalities and was associated with slightly but insignificantly lower TPN costs (not counting Service personnel costs). CONCLUSIONS: Factors such as the general integration of parenteral nutrition into tertiary medical care, standard protocols and order forms, automatic Nutrition Support Service consultations in an affiliated hospital, and nutrition curricula may be responsible for the improvements seen since 1979. However, the addition of automatic Service consultation in 1992 had only a marginal effect on metabolic complications and costs of parenteral nutrition.

Blood Chemical Analysis↗
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Effects of small-peptide and whole-protein enteral feedings on serum proteins and diarrhea in critically ill patients: a randomized trial.

BACKGROUND: It has been proposed that enteral feeding formulas containing small peptides are more efficacious and better tolerated than whole-protein formulas in critically ill patients. METHODS: Intensive care unit patients were stratified with regard to treatment with antibiotics and serum albumin and randomized to treatment with a small-peptide enteral diet or an isoenergetic, isonitrogenous whole-protein diet for 10 days. To assess efficacy, we measured serum prealbumin and fibronectin, and to assess tolerance, we monitored the incidence of diarrhea. A protocol was followed to ascertain all causes of diarrhea (defined as > 200 g stool or > or = 3 liquid stools on 2 consecutive days). RESULTS: Fifty subjects completed the trial. Serum prealbumin and fibronectin increased between 21% and 36% in both groups, but the increase was significant only in the small-peptide group. The change in fibronectin between days 5 and 10 was significantly greater in the small-peptide group (p = .02). Diarrhea occurred in 10 subjects (17.8% of days) receiving small-peptide feeding and 4 subjects (7.5% of days) receiving whole-protein feeding (P = .07 for incidence and 0.03 for prevalence), but the difference was explained by the coincidental use of more diarrhea-causing medications in the former. Only one case of diarrhea could be attributed to tube feeding. CONCLUSIONS: During 10 days of feeding, the small-peptide diet produced slightly greater increases in serum rapid-synthesis proteins than did the whole-protein diet, especially between days 5 and 10. The clinical implications of this difference between the diets are unknown. Both small-peptide and whole-protein diets were well tolerated.

Blood Proteins↗
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Methylenetetrahydrofolate reductase (MTHFR) polymorphism increases the risk of cervical intraepithelial neoplasia.

Although cervical cancer is a common female cancer, little attention has been given to genetic susceptibility factors. The present case-control study was undertaken to examine MTHFR polymorphism as a potential molecular marker of cervical intraepithelial neoplasia (CIN) susceptibility and to relate the findings to smoking, HPV infection, ethnicity, parity and oral contraceptive use, which are known risk factors for cervical cancer. A base change from C to T at the nucleotide position 677 of the MTHFR gene results in substitution of valine (GTC) for alanine (GCC). The homozygous normal (Ala/Ala), homozygous mutant (Val/Val), and heterozygous mutant (Ala/Val) genotypes for the MTHFR gene were determined in cervical tissues of 64 cases of CIN lesions and 31 controls. The genotype frequencies of both Val/Val (17%) and Ala/Val (56%) were significantly higher in subjects with CIN lesions compared to controls with Val/Val (10%) and Ala/Val (39%), (trend p = 0.03). The results suggested a significantly increased CIN risk with an alanine to valine substitution at amino acid 223 of MTHFR with an odds ratio of 2.9 (95% confidence interval: 1.2-7.9, p = 0.02). Age, ethnicity, smoking and oral contraceptive use were weakly and nonsignificantly associated with CIN risk. HPV infection was associated with a statistically nonsignificant threefold increase in CIN risk. Parity and MTHFR genotype displayed a strong interaction. Neither nulliparous women with MTHFR polymorphism nor parous women without the polymorphism were at higher risk than women who did not have children and were MTHFR homozygous normal (the reference category). Women with mutant MTHFR genotype who had children, however, showed a significantly higher risk of CIN, with an odds ratio of 23 (95% confidence interval: 2.3-225) as compared to the reference category. No other factors displayed such a strong pattern of interaction. Since MTHFR polymorphism and pregnancy increases folate requirements and can impair folate status, this association could reflect an inadequate response of mutant MTHFR genotype carriers to the increased demand for folate imposed by pregnancy. Tissue folate deficiency, in turn, could increase the risk of CIN in the affected women.

Adult↗
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Diarrhea with enteral feeding: prospective reappraisal of putative causes.

Our objective was to test, in tube-fed patients whether treatment with antibiotics, the presence of hypoalbuminemia, or the use of hypertonic tube feeding is associated with a higher incidence of diarrhea; how often tube feeding actually causes diarrhea; and whether administration of a Lactobacillus preparation reduces the incidence of diarrhea. Our study design included a randomized, double-blind, placebo-controlled trial of patients on tube feeding for at least 5 days. Stool weights and clinical assessment of bowel function were used as outcome measures. Diarrhea was defined as > 200 g of stool, or three or more liquid stools, in any 24-h period. The tube feeding was considered responsible for diarrhea only when the latter resolved on discontinuation of the feeding. When diarrhea did not resolve, other causes were sought. Of 62 patients enrolled, 41 reached a trial end point. Of these, 34 completed 5 days of feeding without diarrhea, and 7 experienced diarrhea. Although diarrhea was associated with hypoalbuminemia and with protracted treatment with antibiotics, in only 1 subject who had a history of gastric surgery was it caused by tube feeding. The other 6 cases of diarrhea were caused by factors other than tube feeding, mainly drugs administered through the tube. Lactobacillus treatment did not alter the risk of diarrhea. Diarrhea occurs more commonly in tube-fed patients who have low serum albumin levels and have been treated with antibiotics for long periods, but these associations are generally not causal. Hypertonic feeding formulas are not associated with increased risk of diarrhea. Most cases of diarrhea in tube-fed patients are caused by factors extraneous to the tube feeding.

Adult↗
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Dietary habits of first-year medical students assessed during clinical nutrition course.

To enhance the Introduction to Clinical Nutrition course at the University of Alabama at Birmingham, medical students taking the course from 1989 to 1992 (n = 616) were required to analyze by computer the nutrient composition of their own diets for a 24-h period. In 1991 and 1992, they were required to repeat the analysis at the completion of the course. Overall, fat comprised 30% of energy intake, and along with saturated fat and the cholesterol-saturated fat index, it declined virtually each year compared with the previous year. Significant changes were noted by the end of the course in 1991 and 1992 compared with the beginning, when fat comprised 26% of energy, and more students adhered to recommendations for dietary fat, saturated fat, and fiber. Vitamin C intakes exceeded the recommended dietary allowance by more than twofold and increased further by the end of the course in 1991 and 1992, probably indicating an increase in fruit and vegetable intake. Each year, most students rated the dietary assessment as moderately or very useful. These data suggest that dietary self-assessment is a useful tool for teaching clinical nutrition in medical schools and that, even before instruction in clinical nutrition, medical students are favorably altering their dietary patterns to a greater extent than the general population.

Adult↗
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Antioxidant status, fatty acids, and cardiovascular disease.

Oxidative modification of low-density lipoprotein (LDL) cholesterol may contribute to atherosclerosis by several mechanisms demonstrated in vitro. Antioxidants have been shown to inhibit this process in vitro, and there is evidence from animal studies that they protect against atherosclerosis in vivo. The results of human studies examining the association between antioxidants and cardiovascular disease (coronary heart disease, hypertensive heart disease, and stroke) have been equivocal, although evidence is accumulating that suggests a beneficial effect. Recently, monounsaturated fatty acids incorporated into LDL have been shown to be resistant to oxidation in vitro, compared to polyunsaturated fatty acids. Results from short-term clinical studies are consistent with this finding, as are some epidemiologic data, which suggest that diets containing monounsaturated fatty acids are associated with decreased mortality from cardiovascular disease. The overall roles of antioxidants and particular fatty acids in preventing atherosclerosis require further elucidation.

Animals↗
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Randomized trial of tolerance and efficacy of a small-peptide enteral feeding formula versus a whole-protein formula.

Enteral feeding with formulas containing proteins as small peptides may be better tolerated and more efficacious than whole-protein diets, particularly in critically ill patients. We stratified patients beginning enteral feeding according to treatment with antibiotics or not and serum albumin level (< or = 25 or > 25 g/L) and randomly assigned them to treatment with a small-peptide enteral diet or a whole-protein diet. All causes of diarrhea were ascertained (defined as > 200 g stool or > or = three liquid stools on 2 consecutive days). The study was considered complete when diarrhea occurred, or when substantial feeding had been administered without diarrhea for > or = 5 days. Most of the 41 subjects who completed the trial were critically ill. Eight subjects experienced diarrhea (20%), which was caused by tube feeding in six patients (four consuming the small-peptide diet and two consuming the whole-protein diet) and by other factors in two (one on each regimen). Diarrhea was not associated with serum albumin, treatment with antibiotics, or critical illness. There were no differences between treatment groups regarding changes in serum prealbumin or fibronectin. During 5 days of feeding, a small-peptide diet and a whole-protein diet produce similar rates of diarrhea and similar changes in serum proteins.

Diarrhea↗