Download 3) DRUG USE

Mitigating the consequences of
GASTRECTOMIZED ITALIAN ELDERLY PATIENTS
Introduction
Before the 1970s gastrectomy was a commonly used operative treatment for peptic ulcer. Today
some of the gastrectomized elderly patients are suffering from malnutrition. Here we suggest
ways to mitigating the consequences through special dieting.
Background
Gastrectomy
Malnutrition
Dieting
Method
A study over gastrectomized italian elderly patients was conducted ….
Results
index of malnutrition …
Discussion
Need for special diet
Conclusion
Mitigating the consequences
SOME RELIEVES OF THE NUTRITIONAL STATUS AND
THE DIETARY PATTERNS IN A GROUP OF GASTRECTOMIZED ITALIAN
ELDERLY PATIENTS
INELMEN EMINE MERAL……………………………
INTRODUCTION
The prevalence rate for protein-energy malnutrition increases with aging: it has been described to be
between 5% and 10% among community-dwelling older people, 30%-60% among institutionalized
patients and 35%-65% in hospital units (1). A lot of works have described the tight correlation
elapsing between malnutrition and postoperative morbidity risk (2, 3, 4), prolonged hospital-stay
(5), re-admission (6) and mortality (7). Thus the geriatric assessment must include a careful
evaluation of the nutritional status.
A correct nutritional assessment begins evaluating the presence of risk factors for malnutrition;
among these, gastrectomy must be taken in account (8). Gastrectomy leads to well-known
mechanical and biochemical alterations in nutrient absorption, but their effective impact on the
nutritional status has not been pointed out yet. The study of gastrectomy as risk factor for
malnutrition becomes even more difficult in the elderly population, which lacks of a clear definition
of both anthropometrical and nutritional parameters ( BIBLIOGRAFIA;BARBARA).
Before the 1970s gastrectomy was a commonly used operative treatment for peptic ulcer (9, 10).
The majority of these patients, who were middle aged at the time of operation, have entered the
elderly population (10, 11). The decline in duodenal ulcer disease and the increasing effectiveness
of drug therapy have dramatically diminished the need for ulcer surgery (12, 13).
Up to now there are few data on the nutritional consequences of gastrectomy in the elderly subjects
(9, 11, 18, 19, 20).
The aim of this work was to describe the nutritional status of a sample of gastrectomized
hospitalized elderly patients, taking in consideration also the presence of other risk factors for
malnutrition related to aging, compared to a matched sample of non-operated elderly patients.
METHODS
SUBJECTS
This survey was performed in the Geriatric Hospital and S. Antonio Hospital in Padua, Italy,
between May 2000 and November 2001. Hospitalized patients reporting gastric operations in their
anamnesis (total gastrectomy, subtotal gastrectomy, vagotomy plus antrectomy) were selected
among those undergoing Esophagogastroduodenoscopy (EGDS). Endoscopy confirmed this
information and indicated, in each case, the operative method: Billroth I (BI), Billroth II (BII) or
Roux-en-Y anastomosis (RY) (bibliografia Barbara). The time elapsed between the date of
operation and that of investigation was longer than two years. The survey included only patients
operated because of peptic ulcer or Early Gastric Cancer (EGC) (bibliografia). In the EGC the
histological samples had to be negative for recurrence of disease.
We studied patients 65 aged and over with absence of severe diseases influencing nutritional status
(severe cardiovascular, liver, renal, endocrine, respiratory and/or neoplastic diseases). The patients
included in the study underwent EGDS for several indications (dumping syndrome, epigastric pain,
dyspepsia, chronic gastritis). A brief questionnaire included social and economical conditions,
education level, medications use, lifestyle, co-morbidity; depression symptoms revealed with
Geriatric Depression Scale (bibliografia)
Non-operated subjects were chosen so as to match the operated subjects in terms of age, gender,
chronic diseases, drugs and socioeconomic conditions.
In this way 13 gastrectomized patients and 14 non-operated patients were thus identified. Among
these, one gastrectomized subject refused to take part in the study, while two others had their EGDS
suspended by the decision from their own physician. One patient whose case history indicated
surgery for peptic ulcer was excluded because of a pyloroplasty.
Final sample included 10 operated patients (OP) and 13 non-operated patients (NOP).
BLOOD ANALYSIS
An overnight blood sample was taken from each patient to determine the following biochemical
indexes relating to metabolism and nutritional status: Hemoglobin (Hb) and full blood count, serum
protein (Total, Albumin, Retinol Binding Protein (RBP), Ferritin, Transferrin), serum Acid Folic,
Vitamin B12, plasma Glucose (fasting), Uric Acid, Total Cholesterol, HDL-cholesterol,
Triglycerides, Urea nitrogen, Creatinine, PCR, VES, Amylase, Lipase, Total Bilirubin, Alanine
Aminotransferases (ALT), Aspartate (AST), Alkaline Phosphatase (ALP), GGT, Prothrombin Time
(PT), INR, Partial Thromboplastin Time (PTT), Ions (Sodium, Potassium, Chloride, Plasma
Calcium, inorganic Phosphorus, Iron) .
Individuation of anemic patients was conducted according to hemoglobin levels fixed by W.H.O.
(Hb<13 g/dl for males and <12 g/dl for females) (26).
ANTHROPOMETRY (Sergi)
Anthropometrical measurements were taken by using standardized procedure (27).
Height (H) and Weight (W) were measured with subjects wearing light clothing and no shoes.
Weight was measured on a balance beam platform scale to the nearest 0.1 kg; the standing height
was taken by a stadiometer fixed to the wall to the nearest 0.5-cm. For bedridden patients (one
gastrectomized patient) measures were derivated using the following formulas (27):
in men W [kg] = (0.98 x CC) + (1.16 x Kh) + (1.73 x MAC) + (0,37 x SST) – 81,69 and H [cm] = (2.02 x Kh [cm]) –
(0.04 x age [years]) + 64.19; in women W [kg] = (1.27 x CC) + (0.87 x Kh) + (0.98 x MAC) + (0.4 x SST) – 62.35 and
H [cm] = (1.83 x Kh [cm]) – (0.24 x age [years]) + 84.19,
where CC[cm]=Calf Circumference,
Kh[cm]=Kneeheight, MAC[cm]=Mid-arm Circumferences, SST [mm]=Subscapular Skinfold
Thickness. Kneeheight represented the distance from the sole of the foot to the anterior surface of
the thigh, measured on the leg of the subject while seatedTriceps (TST), Biceps (BST) and Scapular
(SST) Skinfold Thickness were measured on the non dominant side of the body, by using a
Harpenden caliper to the nearest 0.2-mm; three measurements were undertaken and averaged.
Skinfold Measurement evaluates subcutaneous fat, which constitutes about 30% of body fat-mass
(28).
MAC and CC were measured on the non dominant arm while it was in relaxed state, by means of a
plastic tape with a precision of 1 mm.
These measurements were used to calculate Body Mass Index (BMI= weight [kg]/height [m] 2) and
Mid-Arm Muscle Circumference (MAMC [cm]= MAC [cm]- 0,314 x TST [mm]). According to the
cut off values established by W.H.O. in 1997 (29), subjects were classified into five categories:
underweight (BMI<18,5 kg/m2), normal weight (18,5-24,9 kg/m2), overweight (25,0-29,9 kg/m2),
moderate obesity (30,0-34,9 kg/m2), severe obesity (35.0-39,9 kg/m2), morbid obesity (40 kg/m2).
MAC and MAMC were used as index of free-fat mass (FFM) (27).
Anthropometrical measurements were compared to values produced by the Euronut-Seneca Study
on the Italian elderly population, taking the 10th centile as cut off for malnutrition (30).
DIETARY SURVEY
In epidemiological and clinical studies nutritional surveys are carried out through the use of three
classic methods: the 24-hour Recall, the Diet History and the 3 Day Record (31). This study utilized
the “Modified Dietary History” according to Burke (32), a method that has already been validated
for the elderly people by confrontation with the 3 Day Record (33). . Nutritional parameters were
obtained by a high standardized methodology and data were collected by a trained operator.
The trained dietician asked the subject to recall his or her usual dietary intakes in the last 6-12
months before hospitalization; if necessary, the patient was given help in answering by a caregiver
The survey consists of two parts: 1) the interviewer reconstructs dietary habits of the subjects by
means of some questions about the structure of usual meals; 2) a check list of foods of wide
consumption is used to ask each subject about the daily, weekly, monthly or yearly food frequencies
and quantity, expressed either in terms of the weight, measured in grams of each portion, or in terms
of common household measures.
The nutrient composition was estimated by using a food database developed by the Ministry of
Agriculture and Forest and the National Institute of Nutrition which includes 474 types of foods
(34). The composition in percentages of the diet macronutrients (proteins, carbohydrates, lipids and
alcohol) was also evaluated, as was the nutrients density (nutrients/1000 Kcal).
The daily energy and some nutrient intakes were compared to recommended nutrient levels for
Italian population (LARN) (35,36).
Food consumption, diet composition and alimentary habits were compared to the results of the
Multicentric Survey in Europe on Nutrition and the Elderly named Euronut-Seneca Study (30).
The statistical analysis was carried out by using Microsoft Excel.
RESULTS
In our sample gastrectomized patients matched non-operated subjects for age, gender, socioeconomical conditions, education level, depression symptoms.
The OP group consisted of 6 men and 4 women, with a median age of 81,17,3 years (range 65-91);
the NOP group consisted of 4 men and 9 women, with a median age of 82,57,3 years (range 7093). The operative methods were Billroth II (6 patients), Billroth I (1 patient) and Roux-en-Y
anastomosis (1 patient); in two subjects the type of gastric reconstruction performed was not
refered. Time from operation was longer than 20 years, except one case (two years).
Only one patient reported in case history postoperative dumping syndrome; however symptoms
disappeared spontaneously. One patient with Early Gastric Cancer suffered dyspeptic syndrome for
the presence of anastomotic stenosis.
1) SOCIAL FACTORS AND LIFESTYLE
Socio-economical status and co-morbidity did not differ between the two groups, with a prevalence
of medium low incomes.
Educational level was slightly higher in OP (6,54,2 years) than in NOP (4,21,7 years).
Smoking habits were more frequent in OP (20% smokers, 40% ex-smokers) than in NOP (77% nosmokers).
There were no considerable differences in alcohol consumption in the two groups.
3) DRUG USE
The two groups did not differ for average number of drugs used per day (OP 5 drugs, range 1-9;
NOP 4 drugs, range 1-10).
Consumption of drugs for dyspepsia was higher in OP (7 subjects) than in NOP (3 subjects).
Particular attention was paid in evaluating the use of dietary supplements, drugs affecting
metabolism and impairing nutrients absorption (37, 38). In OP group 3 patients periodically used
group B vitamin supplements and one patient assumed iron supplements. Two NOP patients used
calcium and vitamin D supplements.
4) BIOCHEMICAL ANALYSIS [Tab. n°1](da modificare la tabella per singolo paziente
eventualmente)
a) Hemoglobin, iron, vitamin B12, acid folic
Average hemoglobin values were similar (mean values OP 11,72,3 g/dl; mean values NOP
12,72,7 g/dl).verificare Barbara)
6 OP subjects were anemic, with hemoglobin values less than 10 g/dl in one of these: normocyticnormocromic anemia affected 2 patients (one of these treated with iron supplements), macrocyticnormochromic anemia 2 patients, normocytic-hypochromic 1 patient; one subject presented a
macrocytic-hypochromic anemia.
In NOP group anemic patients were 4, with hemoglobin values less than 10 g/dl in 3 of these. There
was normocytic-normochromic anemia in 2 patients, macrocytic-normochromic anemia in 1 patient
and macrocytic-hypochromic anemia in one other patient.
Average mean corpuscular volume (MCV) did not differ. Iron values were lower in OP (average
value 58,624,7 mcg/dl) than in NOP (average80, 730,9 mcg/dl). Iron values less than normal
were present in 4 OP and 1 NOP; one of those assumed iron supplement.
Vitamin B12 deficit was present in 1 control, with macrocytic-hypochromic anemia.
No other vitamin B12 neither acid folic deficit were detected.
b) Lipoproteins (in tabella mettere per singolo caso)
OP group presented with lower tryglicerides (79,433,7 mg/dL) and total cholesterol level
(180,432,4 mg/dL) than NOP (tryglicerides 121,564,4 mg/dL, total cholesterol 197,151,6
mg/dL), while HDL cholesterol was higher (OP 52,625,6 mg/dL, NOP 38,59,6 mg/dL).
d) Glucose metabolism (aggiungere alla tabella)(in tabella per singolo caso)
Mean fasting glucose levels were remarkably lower in OP. Mellitus diabetes (fasting glucose  126
mg/dl) was detected in 5 NOP.
e) Serum protein
Differences in albumin, total protein, transferrin and RBP were not significant.
Average total protein concentration was 68,69,0 g/l in OP and 72,08,5 g/l in NOP. Two OP and 1
NOP were hypoproteinemic; one OP and one NOP were hypoalbuminemic. Four OP and two NOP
had subnormal RBP concentrations; indeed two OP and four NOP presented subnormal transferrin
levels.
6) ANTHROPOMETRY [Tab. n° 2](Sergi)
All anthropometrical indexes, except height, were lower in OP subjects. More evident differences
were found for BMI in the whole sample and for MAC and MAMC in operated women.
However, the mean BMI was still normal (22,64,9 kg/m2) in OP group; one subject was
underweight (BMI 13,2 kg/m2) and one obese (BMI 31,8 kg/m2). Among NOP subjects (mean BMI
28,83,5 kg/m2), most patients were overweight (5 subjects) or obese (6 subjects); only 2 patients
had normal BMI.
7) DIETARY INTAKE [Tab. n°3,n° 4]
The mean energy intakes were 1576,2475,0 Kcal/day (women) and 2217,3744,6 Kcal/day (men)
for OP; 1641,7541,5 Kcal/day (women) and 2144,8652,0 Kcal/day (men) for NOP. In both
groups most of the patients (5 OP and 7 NOP) consumed values lower than LARN (1700 Kcal/day
in women and 2000 Kcal/day in men) (36).
Both groups had similar daily intakes of total protein (OP 60,114,9 g/day; NOP 61,215,5 g/day,
with animal protein amounting respectively to 59,5% and 61,0%), carbohydrates (OP 233,655,1
g/day; NOP 247,078,4 g/day) and total fats (OP 58,921,3 g/day; NOP 59,520,6 g/day, with
animal fat amounting respectively to 53,0% and 52,0% ).
The average total energy intake, except for alcohol, was composed in OP by 53,8% of
carbohydrates, 14,5% of proteins and 31,7% of lipids; in NOP by 54,1% of carbohydrates, 14,5% of
proteins and 31,4% of lipids.(per Barbara da verificare).
Total cholesterol intakes were similar (OP 209,9 g/day; NOP 204,8 g/day); 3 OP subjects and 3
NOP subjects assumed more than 255 g/day.(per Barbara da verificare)
Daily intakes of micronutrients were similar in both groups, with mean intakes lower than LARN
values (35) for calcium, riboflavin and retinol.
OP consumed lower amounts of fiber than NOP; however, only 6 NOP subjects consumed more
than 23 g/day of fiber.
Alcohol consumption was reported by 40% of OP (3 men and 1 woman) and 38% of NOP (3 men
and 2 women). The mean daily intake was 43,394,5 g for OP and 15,331,8 g for NOP, providing
respectively 10,1% and 4,2% of the total energy intake. Among men, alcohol consumption was
higher than values recommended by LARN (35).(per Barbara da verificare)
Food consumption, diet composition and alimentary habits are illustrated in table .....
The pattern of single food consumed was similar. Among cereals, pasta, white bread and rice were
more widely consumed. Fish and offal were less consumed than red and white meat and eggs. Most
favorite cheeses were Asiago, Stracchino, Grana and Parmigiano. Among fruits, there was a
greater consumption of apples, peach, grapes, bananas and oranges, and, among vegetables, of
french beans, lettuce, tomatoes, red chicory and courgettes.
Most subjects used oil fats (especially olive oil); however butter consumption was quite widespread.
Among OP there was a smaller consumption of milk, fresh fruits and vegetables, and a greater
consumption of meat and alcoholic drinks (wine, beer).
DISCUSSION
The nutritional outcomes of gastric operations have already been studied in the adults but poorly in
the elderly population (BIBLIOGRAFIA). The most common impairments are maldigestion of
polymeric foods, with malabsorption of calories, iron deficiency, sustained underweight and
abnormal satiety (13). Those abnormalities have been attributed to pancreatico-biliary insufficiency,
bacterial overgrowth and rapid gastric emptying (15,16). There is no doubt that several
consequences result from gastric operations; nevertheless, the prevalence rate and the nutritional
impairment of each survey can be debated, because of the heterogeneity of the various follow-up
analyses and the presence of an individual susceptibility (13). Otherwise, according to other
authors, malnutrition is not an inevitable consequence of gastrectomy, the most common
mechanism responsible for postoperative malnutrition being inadequate intake (15, 17). Hence,
according to these data of the literature, we decided to study a long- term nutritional follow- up after
gastrectomy in hospitalized elderly subjects.
The low prevalence rate of gastrectomized elderly patients restricted our sample (18); the sample
was selected from hospitalized elderly subjects, hence there was a high prevalence rate of chronic
diseases. Besides, another problem was the application of a valid diet survey to an elderly
population in our country. In fact, the recommended nutrient levels (LARN) in Italy, (35) are valid
only for a population up to 60 years old, while all the elderly people are placed in an unique
“geriatric” group of age, over 60 (30). So we had difficulty to choose the best nutritional cut offs.
Moreover, in order to overcome the problem and to obtain accurate data concerning nutritional
intakes in elderly people, we decided to apply the “Modified Diet History” according to Burke,
which we consider a valid method in advanced age (30) (BIBLIOGRAFIA PRECEDENTE
EURONUT INELMEN2000). Then, in an elderly population, there is the high heterogeneity of
subjects, which obstacles the nutritional evaluation (39). In addition, these subjects were
hospitalized, so they had pathologies which could have influenced their nutritional status(40).
1) SOCIAL FACTORS AND LIFESTYLE
Social, economic and psychological factors may considerably affect the nutritional status in the
elderly subjects (41,42). However in the present study these factors do not influence the nutritional
status in both groups. Several investigators have noted a greater consumption of alcohol and
tobacco in gastrectomized subjects (10, 43). Mellstrom and Rundgren (18) suggested that smoking
could be a synergistic factor in several of the long-term complications after partial gastrectomy,
such as reduced body weight. In the present report smokers and ex-smokers frequency were greater
in OP. While, we did not observe a great difference in alcohol consumption between the two
groups, probably in accordance with cultural habits (30).
3) DRUGS
The average older person living at home with multiple concurrent problems may use from three to
seven (or more) different medications daily at any given time (37). The diffuse multiple drug use in
this study confirms this findings.
Nutrient (food) and drug interactions are likely to occur in elderly patients not only because of drugor food-induced alterations in nutrient and drug disposition, respectively, but also because of non
uniform organ deterioration, underlying chronic diseases, dietary regimens, already compromised
nutritional state, and other factors related to aging (37). The adverse effects of drugs may affect
nutritional status impairing eating capacity for anorexia (digoxin, furosemide, levodopa, etc.) and
dyspepsia (acetylsalicylic acid, ranitidine, iron oral supplement, etc.), reducing digestive or
absorptive capacity or adversely affecting nutrient utilization (48). Thus it would be interesting to
evaluate if drugs use may worsen nutritional status in gastrectomized elderly patients. We did not
observe a possible link between drugs use, anthropometric indexes and nutritional intakes in our
work, but the sample, as cited above, was little and showed a great heterogeneity in drug therapy.
4) HEMOGLOBIN, IRON, VITAMIN B12 AND FOLATE
Gastrectomized elderly subjects may be in a particular risk situation for anemia, as the outcomes of
gastric resection may aggravate the slight decrease in the hematological indexes caused by
increasing age (49).
The most common form of anemia in gastrectomized subjects is iron deficient anemia, followed by
mixed anemia (macrocytic-hypocromic anemia) and, lastly, purely macrocytic anemia from B12 or
folic acid deficit (13). In a twenty-five years follow-up investigation conducted by Fischer (10), the
prevalence rate of anemia due to iron or vitamin B12 deficiency was 7%, with 75% of the cases
occurring within 15 years after operation. In the present work the prevalence rate of anemic patients
was slightly higher in the operated group, as described by Mellstrom and Rundgren too (18).
The reported prevalence of iron deficiency after gastric operations varies widely, ranging from 5%
to 62%, and depends somewhat on the defying criteria and the duration of follow up (13, 11). Its
prevalence increases with time after operation, most rapidly in the first 10 years after surgery, but
prevalence continues slowly to increase thereafter (10, 11, 13). According to this finding, in the
present report gastrectomized elderly patients presented a higher trend toward iron deficiency.
Gastrectomy reduce iron absorption in different ways (13, 49). The most important mechanism is
the reduction of acid and pepsin secretion, impairing the conversion of ferric iron to the more
absorbable ferrous iron, and the uncontrolled rapid emptying, which allows the rapid passage over
the principal sites of absorption in the duodenum and upper jejunum (11).
Inadequacy of dietary intake of iron may play some role too (13, 49), but nowadays no findings
confirm this hypothesis. In fact Baird et al. (13, 50) found iron intake to be low in patients with
partial gastrectomies although still adequate for otherwise normal individuals while Mellstrom e
Rundgren (13, 18) reported a high prevalence of anemia after Billroth gastrectomies despite normal
intakes of iron. The results of the present work seems to confirm these findings; in fact iron intake
was low, but no different from non operated patients.
Clinically overt vitamin B12 deficiency is uncommon, even after total gastrectomy, afflicting fewer
than 1% of patients (13, 51, 52). This fact can be attributed to an increased secretion of intrinsic
factor (even 100-fold more than needed) by the oxyntic mucosa (13, 53, 54).
As several investigators have noted (18, 19, 20), vitamin supplements were more widely used by
gastrectomized patients, so that no OP subject presented folic or B12 deficit.
According to this findings, in the present study no cases of vitamin B12 or folic deficiency were
disclosed; mean serum concentration were normal and similar in both group. Commentare perchè
non c’è carenza (assunzione di integratori?) (Barbara)(bibliografia)
5) LIPOPROTEINS, CALCIUM AND GLUCOSE METABOLISM
In the gastrectomized subjects studied by Glober et al. (43), total serum cholesterol averaged 12
mg/100 ml lower than in the general population. The differences in plasma lipoprotein fractions
consisted in depressed LDL and higher HDL, while variations in triglyceride and VLDL were not
significant. Our results seem to confirm this effect of gastrectomy on serum lipids.
Intake of calories and fat in gastrectomized patients seems to be similar to that in the general
population (43), thus suggesting that the lower lipid values may be due to malabsorption (55, 13).
Different mechanisms may contribute to the pathogenesis of fat malabsorption after gastric
resection: defective emulsification of ingested fat, elimination of early postcibal peak of pancreatic
enzyme secretion (altered effectiveness of postcibal secretion of enzymes from the pancreas),
bacterial overgrowth, rapid intestinal transit (13,15).
The examination of glucose metabolism showed a lower prevalence rate of diabetes among
gastrectomized subjects, corresponding to the findings of other investigators(18).
PROTEINS
A unique evaluation of biochemical markers of malnutrition (total protein, albumin, RBP, ferritin,
transferrin) lacks of enough sensibility and specificity (40), as different factors can alter blood
protein levels (underlying diseases, infections, stress) (27, 59). Anyway several investigators have
observed no relationship of intake with blood protein concentrations, when studying elderly
subjects (60, 61). The present study did not find any difference in protein dietary intake and blood
proteins levels between the two groups
9) ANTROPOMETRIC INVESTIGATION
As previously noted, in the present study the coexistence of two particular conditions, gastrectomy
and elderly age, has influenced both the way of execution and the interpretation of the results. Some
preliminary considerations are so necessary.
Firstly, we found some difficulties in choosing which anthropometric cut-off values to apply to our
sample. .
Nevertheless ……Comunque possono essersi verificate delle piccole differenze nelle
singole rilevazioni
As body composition changes in aging, all anthropometric measurements have to be differently
interpreted for elderly subjects (47, 62). In particular, several investigators advocate the adoption of
different cut-off values for BMI, lowering the risk of overestimate both obesity and undernutrition
(59, 62, 63, 64, 65). As the debate is still open, we decided to adopt the cut-off values established
by W.H.O. in 1997 (29), although they refer to an adult population.
In the present study the mean values of BMI and the percentage of overweight and obese patients
were higher than in other epidemiological works evaluating hospitalized elderly patients (59).
However, the study had excluded the subjects affected by severe disease influencing nutritional
status. On the other hand, it must be taken in account that different works may use different cut-off
values, so that the results are not easily comparable.
BMI values were quite elevated in both groups, despite several subjects assuming daily energy
intake lower than recommended. These findings correspond with those of other studies (60, 67, 68)
evaluating the nutritional status in elderly population. Several factors could explain the
phenomenon. Firstly, energy expenditure was not taken in account in our work. Dietary history may
be limited in elderly subjects by poor compliance (30) and, in obese subjects, by voluntary
underestimation of self-reported energy intake (67). Lastly, BMI is the reflection of a previous long
period of energy intake and may not be related to energy intake measured at the time of the study
(60). However, our data refer to the usual dietary intakes in the last 6-12 months before
hospitalization.
Another problem in the study of anthropometric measurements in elderly gastrectomized subjects is
that long-term follow ups of body weights after gastric resection are seldom reported; furthermore,
there is no uniformity, as patients’ weights are variously reported in comparison with age- and sexmatched, normal subjects (13). However there is a general agreement about the maintenance of
reduced body weight after gastrectomy in most patients, prevalence of underweight varying
between 15% and 80% (18, 69). Our data too confirm a trend in gastrectomized patients towards
lower BMI values; however mean value was still acceptable. It seems probable that weigh loss
associated with aging is higher in gastrectomized subjects than in those non operated (18).
Another alteration in anthropometric measurements is the lower fat-free mass in elderly
gastrectomized women (58), as expressed in our study too by lower MAC and MAMC
measurements; but it is difficult to explain (focus) this difference between genders.
Several factors out of operation may contribute to weight loss (educational level, socio-economical
conditions, dentition status, drug use, alcohol consumption, smoking) As previously debated, in the
present work gastrectomized subjects differed only for common smokers, as noted by other authors
(18). Otherwise smoking alone cannot explain weight loss after gastric resection (18).
So, attention should be focused on the operation itself, for its direct and indirect consequences, first
of all malabsorption. Even if it is well proved that nutrients absorption is somewhat altered by
gastric resection depending to the different type of gastric reconstruction performed, substantial
underweight comes invariably after both total and subtotal resection (13, 69). Hence, factors other
that malabsorption must be implied. (per SERGI).
DIETARY PATTERNS
Several authors have focused their attention to lower food intakes as the main cause of weight loss
(13, 17). Gastrectomized patients are physiologically capable of caloric intake sufficient to result in
weight gain in the absence of significant malabsorption (17), but several studies have noted that
they keep reduced energy intakes (17, 49, 70). An inappropriate satiety may arise after gastrectomy,
despite prolonged underweight (13). Anorexia is probably due to either emotional factors or
chemical mediators acting centrally on hypothalamus (16).
According to some authors (71, 20), the most important factor to maintain an adequate nutritional
intake would be the ability to control postprandial symptoms. Up to 19% operated subjects still
complain postprandial symptoms 20-30 years later (10, 49), but in spite of this condition, most of
the patients seem satisfied of operation (10). Our data too seems to confirm this idea. In fact, only
two patients complain of severe postprandial symptoms, but their energy intakes were otherwise
satisfactory, thanks to the use to consume small and frequent lunches, as suggested by clinicians
(12).
In the present study, mean energy intake in gastrectomized patient was similar to that of non
operated subjects. According to several other authors (18, 19, 58, 72), we can so suppose that lower
energy intake alone can not explain the presence of antropometric and biochemical differences
observed in nutritional status. One interpretation is that the intake of food in the underweight,
resected patients had risen from previously subnormal to normal amounts in partial compensation
for the weight lost, but that the normal intake was still inappropriately low for the sustained
underweight. Furthermore***4 under these conditions, malabsorption too might then become a
significant factor in the production of malnutrition (17).
In addition to a balanced amount of food intake, a wise choice of food types is considered important
for health (73). In this respect, dietary quality of our sample was evaluated.
Analyzing the composition of the diet in our subjects, we can remark the characteristics of the
Italian
variant
of
the
traditional
Mediterranean
diet
(BIBLIOGRAFIA
EURONUT
INELMEN2000). This diet is characterized by abundant plant foods (fruit, vegetables, breads, other
forms of cereals, potatoes, beans, nuts, and seed), fresh fruit as the typical daily dessert, olive oil as
the principal source of fat, dairy products (principally cheese and yogurt), and fish and poultry
consumed in low to moderate amounts, zero to four eggs consumed weekly, red meat consumed in
low
amounts,
and
wine
consumed
in
low
to
moderate
amounts,
normally
with
meals(BIBLIOGRAFIA EURONUT INELMEN2000). . This diet is low in saturated fat (<= 7-8%
of energy), with total fat ranging from <25% to >35% of energy (74). These data correspond well
with the findings of other Italian studies (30, 75). (BIBLIOGRAFIA EURONUT INELMEN2000).
The gastrectomized elderly patients seem to keep dietary habits substantially similar to nonoperated subjects. Frequency of milk consumption was smaller among operated subjects, but
partially compensated by the use of dairy products, so that calcium intake was similar in both
groups. Calcium intake was lower than recommended (35), a common problem in elderly
population (30).
The data concerning fiber consumption are interesting. We can suppose that motility alterations
occurring after gastric surgery (76) may alter fiber digestion, as confirmed by the high incidence of
phytobezoars following gastric surgery (77). This complain could explain why gastrectomized
subjects avoid vegetable and fibrous fruit.
CONCLUSIONS