Publications by authors named "Kristina Norman"

95 Publications

Association between meal-specific daily protein intake and lean mass in older adults: results of the cross-sectional BASE-II study.

Am J Clin Nutr 2021 May 8. Epub 2021 May 8.

Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Department of Endocrinology, Diabetes and Metabolism, Berlin Institute of Health, Berlin, Germany.

Background: Adequate total and meal-specific protein intake is considered an important prerequisite to preserve appendicular lean mass (ALM) in older adults and to prevent sarcopenia.

Objectives: We analyzed the meal-specific protein intake across the main meals between participants with normal vs. low ALM to BMI ratio (ALMBMI).

Methods: 782 participants [59.6% men; median 69 (IQR: 65, 71) y] of the Berlin Aging Study II have been included in this analysis. ALM was assessed by dual X-ray absorptiometry. Low lean mass was defined as ALMBMI using recommended sex-specific cut-offs. A 5-day nutritional protocol was used to assess total and meal-specific protein intake.

Results: Median total protein intake was 0.89 (IQR: 0.74, 1.05) g/kg/d body weight (BW) in participants with low ALMBMI and 1.02 (IQR: 0.86, 1.21) g/kg BW in participants with normal ALMBMI (P < 0.001). Daily protein intake at breakfast was similar in both groups [0.23 (95% CI: 0.20, 0.26) vs. 0.24 (95% CI: 0.23, 0.26) g/kg BW; P = 0.245]. Subjects with low ALMBMI reported a lower protein intake at lunch and dinner compared with those with normal ALMBMI [0.29 (95% CI: 0.27, 0.32) vs. 0.35 (95% CI: 0.34, 0.36) g/kg BW; P = 0.001 and 0.32 (95% CI: 0.30, 0.35) vs. 0.36 (95% CI: 0.35, 0.37) g/kg BW; P = 0.027, respectively]. In a stepwise regression model, a higher total protein intake was positively associated with ALMBMI [ß = 0.10 (95% CI: 0.07, 0.13) P < 0.001]. The protein intake at dinner was positively associated with ALMBMI [ß = 0.14 (95% CI: 0.08, 0.19) P < 0.001] irrespective of protein intake at breakfast and lunch. This association disappeared after additional adjustment for total protein intake.

Conclusion: Our data highlight an association of total protein intake and ALMBMI in older adults. Although current data support an association of high ALMBMI with protein intake at dinner in particular, this was not independent from total protein intake and the findings do not allow a conclusion on causality.
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http://dx.doi.org/10.1093/ajcn/nqab144DOI Listing
May 2021

Vitamin D insufficiency is associated with metabolic syndrome independent of insulin resistance and obesity in young adults - The Berlin Aging Study II.

Diabetes Metab Res Rev 2021 Apr 22:e3457. Epub 2021 Apr 22.

Department of Nutrition and Gerontology, German Institute for Human Nutrition Potsdam Rehbrücke, Nuthetal, Germany.

Purpose: Age-related changes affect vitamin D absorption and metabolism. Low 25-hydroxyvitamin D concentrations have been reported as risk factor for the development of metabolic syndrome (MetS). However, recent evaluations suggest this association might be explained by obesity or insulin resistance (IR) in subjects with MetS. Our aim was to analyze associations between vitamin D insufficiency and MetS in a young cohort without diabetes and two senior cohorts with and without diabetes.

Methods: Four hundred sixteen young and 1357 older BASE-II participants were analyzed. Type 2 diabetes (T2D) was defined according to European Society of Cardiology (ESC) guidelines, MetS as suggested by International Diabetes Federation/American Heart Association/National Heart, Lung and Blood Institute (IDF/AHA/NHLBI 2009). Vitamin D insufficiency was defined as 25-hydroxyvitamin D concentrations <50 nmol/L. Among other confounders, BMI and IR were taken into account.

Results: MetS was prevalent in 7.7% of the young and in 35.6% of the older BASE-II participants and T2D occurred in 12.7% of the older participants. In young subjects without diabetes, vitamin D insufficiency was associated with an independent 3.2-fold increased odds of having MetS (OR: 3.2 CI: 1.0-8.7; p = 0.042). However, in the older participants, this association was lost once BMI was taken into account among those with diabetes, and once IR was taken into account among those without diabetes.

Conclusion: Independent associations between vitamin D insufficiency and MetS were only found among young subjects without diabetes. In the older adults, BMI annihilated these associations among subjects without diabetes as did HOMA-IR among subjects with diabetes.
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http://dx.doi.org/10.1002/dmrr.3457DOI Listing
April 2021

Dietary supplement use in ambulatory cancer patients: a survey on prevalence, motivation and attitudes.

J Cancer Res Clin Oncol 2021 Apr 6. Epub 2021 Apr 6.

Department of Geriatrics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Reinickendorfer Str. 61, 13347, Berlin, Germany.

Purpose: Patients with cancer often believe dietary supplements (DS) such as micronutrients and botanical products to be health supporting and non-toxic despite growing concerns regarding potential pharmacological interactions. Studies on the prevalence of DS use among patients with cancer are heterogeneous and mainly conducted at university-based cancer centers. This survey focused on a particular cancer patient group treated in an ambulatory setting without regular access to professional nutritional counselling.

Methods: Patients with a history of cancer or hematological malignancy were included in this survey. A self-reported questionnaire was used to evaluate the different aspects of DS use, changes in dietary habits and patients' demographic characteristics.

Results: Almost every second patient reported using DS (47.2%). Women (56.3%), patients with an academic degree (56.0%) and non-smokers (84.8%) were more inclined to use DS. Along with magnesium (16.6%), calcium (14.3%), multivitamins (12.0%) and vitamin C (9.4%), use of herbal supplements (12.6%) was common. Women (84.8% vs. 74.9% of men, p =  < 0.001) and patients younger than 65 years (84.4% vs. 77.2% of patients > 65 y, p =  0.002) sought dietary advice more often. Support of the immune system was the main reason for DS use (26.4%) and a relevant number of patients (49.6%) reported to have changed their dietary habits following cancer diagnosis.

Conclusion: DS use is common among patients with cancer treated in an ambulatory setting. This finding should encourage oncologists to implement detailed questioning about DS use and dietary habits to prevent potential interactions and offer substantial advice.
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http://dx.doi.org/10.1007/s00432-021-03594-7DOI Listing
April 2021

Underweight in Nursing Homes: Differences between Men and Women.

Gerontology 2021 20;67(2):211-219. Epub 2021 Jan 20.

Geriatrics Research Group Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,

Objective: In Germany, there is an ongoing concern about the high prevalence of underweight on admission to health-care institutions. In order to assess possible sex-specific differences, the aim of this study is to provide valid figures about the prevalence and risk factors of underweight of men and women in German nursing homes.

Material And Methods: A secondary data analysis of 8 annual consecutive cross-sectional studies of 19,686 residents from 280 nursing homes was conducted from 2009 to 2016. Underweight was defined as BMI < 18.5 (<20) for individuals <65 years (≥65 years). For statistical modeling, we used classification and regression trees (CRTs) and random forest in "R."

Results: Average prevalence of underweight in nursing home residents was 13.7% (13.2-14.2). Initial descriptive results showed that the prevalence of underweight among women was 15.6% (15.0-16.2) and the prevalence of underweight among men was 7.5% (6.7-8.2). The CRT-based modeling indicated that "loss of appetite" as the most important indicator for low BMI. If "loss of appetite" was present, prevalence of underweight increased from 13.5 to 39.1%. Other important indicators were "very large institutions" and the "resident/nurse ratio." The random forest analysis confirmed the importance of the CRT approach.

Discussion/conclusion: The multivariate approach revealed that the role of sex for being underweight in nursing homes is marginal. To avoid higher morbidity and mortality in this group, nutritional intervention by clinical practitioners to increase appetite should be given high priority, especially in large long-term care institutions.
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http://dx.doi.org/10.1159/000512459DOI Listing
January 2021

Age-related fatigue is associated with reduced mitochondrial function in peripheral blood mononuclear cells.

Exp Gerontol 2021 Feb 3;144:111177. Epub 2020 Dec 3.

German Institute of Human Nutrition, Potsdam - Rehbrücke, Department of Nutrition and Gerontology, Nuthetal, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Research Group on Geriatrics, Germany; University of Potsdam, Institute of Nutritional Science, Potsdam, Germany. Electronic address:

Background: Fatigue is a complex syndrome associated with exhaustion not relieved by sleep. It occurs frequently in older adults in the context of chronic disease and is associated with decreased physical capacity. Whether a mitochondrial dysfunction and therefore an impaired energy production might contribute to the development of fatigue during aging is yet unknown. The aim of this study was to evaluate mitochondrial respiration of peripheral blood mononuclear cells (PBMCs) in older patients with and without fatigue.

Method: Fatigue was determined according to the Brief Fatigue Inventory. Mitochondrial respiration of freshly isolated PBMCs was investigated by high-resolution respirometry using the Oroboros Oxygraph-O2k. Functional impairment and depressive symptoms were assessed using questionnaires.

Results: 23 geriatric patients (77.8 ± 4.9 years; 43.5% female) with fatigue and 22 without fatigue (75.4 ± 5.4 years; 45.5% female) were analyzed. Patients with fatigue exhibited more functional limitations and more depressive symptoms. High-resolution respirometry of intact PBMCs revealed a lower routine (4.82 ± 1.14 pmol/s versus 5.89 ± 1.90 pmol/s, p = 0.041) and maximum (6.55 ± 1.51 pmol/s versus 8.43 ± 3.67 pmol/s, p = 0.013) oxygen consumption rate, resulting in a reduced ATP-linked respiration (4.26 ± 1.00 pmol/s versus 5.09 ± 1.53 pmol/s, p = 0.035) of PBMCs from geriatric patients with fatigue compared to controls without.

Conclusions: This short report shows that in this group of older patients, fatigue is associated with lower PBMC mitochondrial respiration. Whether the impaired mitochondrial respiration is accompanied by a reduced mitochondrial activity in other organs (e.g. muscle) remains to be elucidated.
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http://dx.doi.org/10.1016/j.exger.2020.111177DOI Listing
February 2021

Editorial: A different year from any before.

Curr Opin Clin Nutr Metab Care 2020 09;23(5):295

University of Vermont, Burlington, Vermont, USA.

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http://dx.doi.org/10.1097/MCO.0000000000000681DOI Listing
September 2020

Validation of a new prognostic body composition parameter in cancer patients.

Clin Nutr 2021 Feb 23;40(2):615-623. Epub 2020 Jun 23.

Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.

Background & Aims: Estimation errors associated with bioelectric impedance evaluation may affect the accuracy of body composition and its prognostic value. We evaluated the prognostic value of a new body composition parameter (Nutrigram®) obtained from bioimpedance vectorial analysis-derived body cell mass and its association with nutritional and functional status.

Design: Data of Italian and German cancer patients observed prospectively until death were used. Multivariable models (adjusted for age, gender, hydration status, performance status, and disease's stage) were built in both cohorts to assess the association between body composition outcome parameters (low fat-free mass [FFM], <15 [females] and <17 [males] kg/m; low standardized phase angle [SPA], <-1.65; low Nutrigram®, <510 [females] and <660 [males] mg/24 h/m) and 1-year all-cause mortality, low body mass index (BMI; <20 [<70 years] and <22 [≥70 years] kg/m), clinically significant weight loss (WL; ≥10% in 6 months) and low handgrip strength (HG; <20 [females] and <30 [males] kg).

Results: Low Nutrigram® was independently associated with mortality in both Italian (HR = 1.84 [95%CI, 1.18-2.86]; P = 0.007) and German cohorts (HR = 1.52 [95%CI, 1.17-2.07]; P = 0.008). Low FFMI and low SPA did not predict survival in the German cohort. In patients with low Nutrigram®, worse nutritional and functional status were observed in both study populations. Performance of models addressing the study endpoints showed substantial consistency with both cohorts, particularly of those including low Nutrigram®.

Conclusions: We validated a new prognostic body composition parameter, which is easier to interpret than standard nutritional parameters and may be useful for identifying cancer patients at nutritional risk, requiring early nutritional support.
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http://dx.doi.org/10.1016/j.clnu.2020.06.011DOI Listing
February 2021

Relationship between Lipoprotein (a) and cognitive function - Results from the Berlin Aging Study II.

Sci Rep 2020 06 30;10(1):10636. Epub 2020 Jun 30.

Max Planck Institute for Human Development, Berlin, Germany.

It has been suggested that an age-related loss of cognitive function might be driven by atherosclerotic effects associated with altered lipid patterns. However, the relationship between Lipoprotein (a) [Lp(a)] and healthy cognitive aging has not yet been sufficiently investigated. For the current analysis we used the cross-sectional data of 1,380 Berlin Aging Study II (BASE-II) participants aged 60 years and older (52.2% women, mean age 68 ± 4 years). We employed the Consortium to Establish a Registry for Alzheimer's Disease (CERAD)-Plus test battery to establish latent factors representing continuous measures of domain specific cognitive functions. Regression models adjusted for APOE genotypes, lipid parameters and other risk factors for cognitive impairment were applied to assess the association between Lp(a) and performance in specific cognitive domains. Men within the lowest Lp(a)-quintile showed better cognitive performance in the cognitive domain executive functions and processing speed (p = 0.027). No significant results were observed in women. The results of the current analysis of predominantly healthy BASE-II participants point towards an association between low Lp(a) concentrations and better cognitive performance. However, evidence for this relationship resulting from the current analysis and the employment of a differentiated cognitive assessment is rather weak.
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http://dx.doi.org/10.1038/s41598-020-66783-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7326928PMC
June 2020

Associations Between Serum GDF15 Concentrations, Muscle Mass, and Strength Show Sex-Specific Differences in Older Hospital Patients.

Rejuvenation Res 2021 Feb 23;24(1):14-19. Epub 2020 Jun 23.

Department of Nutrition and Gerontology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany.

Aging is accompanied by a progressive decline of muscle mass and strength and also higher levels of circulating cytokines such as growth differentiation factor 15 (GDF15). Studies evaluating the association of GDF15 with muscle mass and strength are rare. In this analysis, we investigated GDF15 concentrations and their relationship with muscle mass and strength in older men compared with women. GDF15 serum concentrations were measured in 103 (60 years and older) hospital patients and an age-matched control group with an immunosorbent assay. Skeletal muscle mass was determined with the bioelectrical impedance analysis. Grip strength and knee extension strength were assessed and normalized for height. Associations between GDF15 concentrations and muscle mass and strength were evaluated with general linear models. Male patients showed higher levels of GDF15 compared with female patients ( = 0.021). Elevated GDF15 concentrations were associated with lower measures of muscle mass, exclusively in men, after adjustment for age and number of drugs per day. Our results indicate sex differences between associations of GDF15 with muscle mass and strength parameters in a cohort of older hospital patients.
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http://dx.doi.org/10.1089/rej.2020.2308DOI Listing
February 2021

Reference Values for Skeletal Muscle Mass - Current Concepts and Methodological Considerations.

Nutrients 2020 Mar 12;12(3). Epub 2020 Mar 12.

Institute for Human Nutrition and Food Science, Christian-Albrechts-University Kiel, 24105 Kiel, Germany.

Assessment of a low skeletal muscle mass (SM) is important for diagnosis of ageing and disease-associated sarcopenia and is hindered by heterogeneous methods and terminologies that lead to differences in diagnostic criteria among studies and even among consensus definitions. The aim of this review was to analyze and summarize previously published cut-offs for SM applied in clinical and research settings and to facilitate comparison of results between studies. Multiple published reference values for discrepant parameters of SM were identified from 64 studies and the underlying methodological assumptions and limitations are compared including different concepts for normalization of SM for body size and fat mass (FM). Single computed tomography or magnetic resonance imaging images and appendicular lean soft tissue by dual X-ray absorptiometry (DXA) or bioelectrical impedance analysis (BIA) are taken as a valid substitute of total SM because they show a high correlation with results from whole body imaging in cross-sectional and longitudinal analyses. However, the random error of these methods limits the applicability of these substitutes in the assessment of individual cases and together with the systematic error limits the accurate detection of changes in SM. Adverse effects of obesity on muscle quality and function may lead to an underestimation of sarcopenia in obesity and may justify normalization of SM for FM. In conclusion, results for SM can only be compared with reference values using the same method, BIA- or DXA-device and an appropriate reference population. Limitations of proxies for total SM as well as normalization of SM for FM are important content-related issues that need to be considered in longitudinal studies, populations with obesity or older subjects.
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http://dx.doi.org/10.3390/nu12030755DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146130PMC
March 2020

Plasma carotenoids, tocopherols and retinol - Association with age in the Berlin Aging Study II.

Redox Biol 2020 05 13;32:101461. Epub 2020 Feb 13.

Institute of Nutritional Science, University of Potsdam, 14558 Nuthetal, Germany; Geriatrics Research Group, Charité - Universitätsmedizin Berlin, 13347 Berlin, Germany; Department of Nutrition and Gerontology, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), 14558 Nuthetal, Germany. Electronic address:

Regular consumption of fruits and vegetables, which is related to high plasma levels of lipid-soluble micronutrients such as carotenoids and tocopherols, is linked to lower incidences of various age-related diseases. Differences in lipid-soluble micronutrient blood concentrations seem to be associated with age. Our retrospective analysis included men and women aged 22-37 and 60-85 years from the Berlin Aging Study II. Participants with simultaneously available plasma samples and dietary data were included (n = 1973). Differences between young and old groups were found for plasma lycopene, α-carotene, α-tocopherol, β-cryptoxanthin (only in women), and γ-tocopherol (only in men). β-Carotene, retinol and lutein/zeaxanthin did not differ between young and old participants regardless of the sex. We found significant associations for lycopene, α-carotene (both inverse), α-tocopherol, γ-tocopherol, and β-carotene (all positive) with age. Adjusting for BMI, smoking status, season, cholesterol and dietary intake confirmed these associations, except for β-carotene. These micronutrients are important antioxidants and associated with lower incidence of age-related diseases, therefore it is important to understand the underlying mechanisms in order to implement dietary strategies for the prevention of age-related diseases. To explain the lower lycopene and α-carotene concentration in older subjects, bioavailability studies in older participants are necessary.
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http://dx.doi.org/10.1016/j.redox.2020.101461DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7030983PMC
May 2020

[Anthropometric measures in the German National Cohort-more than weight and height].

Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020 Mar;63(3):290-300

Abteilung Klinische Epidemiologie und Alternsforschung, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Deutschland.

High levels of adiposity in the population have a major impact on various diseases, but previous epidemiologic studies have largely been restricted to simple anthropometric measures such as the body mass index (BMI), an imperfect predictor of disease risk. There is a critical need for the use of improved measures of relative weight and body composition in large-scale, population-based research.The current article presents initial descriptive results of body composition and fat distribution based on the midterm baseline dataset of the German National Cohort, which included 101,817 participants who were examined in 18 study centers in Germany between March 2014 and March 2017. The anthropometric measures encompassed body weight, height, waist and hip circumference, bioelectrical impedance analysis (BIA), sonography of abdominal adipose tissue, 3D-body scanning, and magnetic resonance imaging.BMI analyses showed that 46.2% of men and 29.7% of women were overweight and 23.5% of men and 21.2% of women were obese. On average, women in almost all age groups demonstrated more subcutaneous adipose tissue layer thickness than men. The mean values of visceral adipose tissue layer thickness, on the other hand, were higher among men than among women in all age groups and increased continuously across age groups in both sexes.The comprehensive assessment of body composition and fat distribution provides novel future opportunities for detailed epidemiologic analyses of overweight and adiposity in relation to the development of chronic diseases.
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http://dx.doi.org/10.1007/s00103-020-03096-wDOI Listing
March 2020

Veganism, aging and longevity: new insight into old concepts.

Curr Opin Clin Nutr Metab Care 2020 03;23(2):145-150

Institute of Nutritional Science, University of Potsdam.

Purpose Of Review: Plant-based diets are associated with better health and longevity. Veganism is a strict form of vegetarianism, which has gained increasing attention in recent years. This review will focus on studies addressing mortality and health-span in vegans and vegetarians and discuss possible longevity-enhancing mechanisms.

Recent Findings: Studies in vegans are still limited. Epidemiologic studies consistently show lower disease rates, such as lower incidence of cancer and cardiovascular disease, but mortality rates are comparable with rates in vegetarians and occasional meat eaters. Reasons for following strict vegan diets differ, which may affect diet quality, and thus health and life-span. New insights into some characteristics of veganism, such as protein restriction or restriction in certain amino acids (leucine or methionine) show potentially life-span-enhancing potential. Veganism improves insulin resistance and dyslipidemia and associated abnormalities. Gut microbiota as mediator of dietary impact on host metabolism is more diverse in vegans and has been suggested to be a health-promoting factor. Vegan diets do not fulfill the requirements of children, pregnant women or old individuals who should receive adequate supplements.

Summary: There is substantial evidence that plant-based diets are associated with better health but not necessarily lower mortality rates. The exact mechanisms of health promotion by vegan diets are still not entirely clear but most likely multifactorial. Reasons for and quality of the vegan diet should be assessed in longevity studies.
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http://dx.doi.org/10.1097/MCO.0000000000000625DOI Listing
March 2020

Phenome-wide association analysis of LDL-cholesterol lowering genetic variants in PCSK9.

BMC Cardiovasc Disord 2019 10 29;19(1):240. Epub 2019 Oct 29.

Department Primary Care & Population Health, University College London, London, UK.

Background: We characterised the phenotypic consequence of genetic variation at the PCSK9 locus and compared findings with recent trials of pharmacological inhibitors of PCSK9.

Methods: Published and individual participant level data (300,000+ participants) were combined to construct a weighted PCSK9 gene-centric score (GS). Seventeen randomized placebo controlled PCSK9 inhibitor trials were included, providing data on 79,578 participants. Results were scaled to a one mmol/L lower LDL-C concentration.

Results: The PCSK9 GS (comprising 4 SNPs) associations with plasma lipid and apolipoprotein levels were consistent in direction with treatment effects. The GS odds ratio (OR) for myocardial infarction (MI) was 0.53 (95% CI 0.42; 0.68), compared to a PCSK9 inhibitor effect of 0.90 (95% CI 0.86; 0.93). For ischemic stroke ORs were 0.84 (95% CI 0.57; 1.22) for the GS, compared to 0.85 (95% CI 0.78; 0.93) in the drug trials. ORs with type 2 diabetes mellitus (T2DM) were 1.29 (95% CI 1.11; 1.50) for the GS, as compared to 1.00 (95% CI 0.96; 1.04) for incident T2DM in PCSK9 inhibitor trials. No genetic associations were observed for cancer, heart failure, atrial fibrillation, chronic obstructive pulmonary disease, or Alzheimer's disease - outcomes for which large-scale trial data were unavailable.

Conclusions: Genetic variation at the PCSK9 locus recapitulates the effects of therapeutic inhibition of PCSK9 on major blood lipid fractions and MI. While indicating an increased risk of T2DM, no other possible safety concerns were shown; although precision was moderate.
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http://dx.doi.org/10.1186/s12872-019-1187-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6820948PMC
October 2019

Severe Weight Loss and Its Association with Fatigue in Old Patients at Discharge from a Geriatric Hospital.

Nutrients 2019 Oct 10;11(10). Epub 2019 Oct 10.

Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Research Group on Geriatrics, Working Group Nutrition and Body Composition, Reinickendorfer Str. 61, 13347 Berlin, Germany.

Although malnutrition is frequent in the old, little is known about its association with fatigue. We evaluated the relation of self-reported severe weight loss with fatigue and the predictors for fatigue in old patients at hospital discharge. Severe weight loss was defined according to involuntary weight loss ≥5% in the last three months. We determined fatigue with the validated questionnaire. The regression analyses were adjusted for age, sex, number of comorbidities, medications/day, and BMI. Of 424 patients aged between 61 and 98 y, 34.1% had severe weight loss. Fatigue was higher in patients with severe weight loss (3.7 ± 2.3 vs. 3.2 ± 2.3 points, = 0.021). In a multinomial regression model, weight loss was independently associated with higher risk for moderate fatigue (OR:1.172, CI:1.026-1.338, = 0.019) and with increased risk for severe fatigue (OR:1.209, CI:1.047-1.395, = 0.010) together with the number of medications/day (OR:1.220, CI:1.023-1.455, = 0.027). In a binary regression model, severe weight loss predicted moderate-to-severe fatigue in the study population (OR:1.651, CI:1.052-2.590, = 0.029). In summary, patients with self-reported severe weight loss at hospital discharge exhibited higher fatigue levels and severe weight loss was an independent predictor of moderate and severe fatigue, placing these patients at risk for impaired outcome in the post-hospital period.
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http://dx.doi.org/10.3390/nu11102415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6835926PMC
October 2019

Prevalence, Risk Factors and Assessment of Depressive Symptoms in Patients With Systemic Sclerosis.

Arch Rheumatol 2019 09 28;34(3):253-261. Epub 2019 Jan 28.

Department of Rheumatology and Clinical Immunology, Charité-Universitatsmedizin Berlin, Berlin, Germany.

Objectives: This study aims to evaluate the prevalence of depressive symptoms among systemic sclerosis (SSc) patients using the Major Depression Inventory (MDI), identify possible risk factors, and analyze the current standard of care to raise awareness and improve clinical care for SSc patients.

Patients And Methods: The study included 94 SSc patients (12 males, 82 females; mean age 58.3±13.6 years; range, 28 to 83 years) who completed the MDI, Short Form 36 Health Survey, Scleroderma Health Assessment Questionnaire, Brief Fatigue Inventory and Physical Activity Questionnaire. Clinical parameters were assessed according to standardized procedures. Discharge letters were analyzed for evaluation of depressive symptoms.

Results: The prevalence of depressive symptoms was 22.3%. It correlated with female sex (p=0.047), underweight (p=0.002), fatigue (p<0.001), decreased quality of life (p<0.001) and less physical activity (p=0.048). The latter three were confirmed as independent risk factors in a multivariable regression analysis. The analysis of the current standard of care revealed no assessment of depressive symptoms in the majority of patients (89.4%), including 19 with depressive symptoms according to the MDI score.

Conclusion: This study confirms the high prevalence of depressive symptoms in SSc patients. There is an unmet need of regular assessment of mental health during SSc consultations. Fatigue, decreased quality of life and reduced physical activity were ascertained as independent risk factors, while special attention should also be paid to weight loss and underweight.
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http://dx.doi.org/10.5606/ArchRheumatol.2019.7111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6768792PMC
September 2019

Anti-Inflammatory Diets and Fatigue.

Nutrients 2019 Sep 30;11(10). Epub 2019 Sep 30.

Department of Nutrition and Gerontology, German Institute of Human Nutrition Potsdam-Rehbrücke, Arthur-Scheunert-Allee 114-116, 14558 Nuthetal, Germany.

Accumulating data indicates a link between a pro-inflammatory status and occurrence of chronic disease-related fatigue. The questions are whether the observed inflammatory profile can be (a) improved by anti-inflammatory diets, and (b) if this improvement can in turn be translated into a significant fatigue reduction. The aim of this narrative review was to investigate the effect of anti-inflammatory nutrients, foods, and diets on inflammatory markers and fatigue in various patient populations. Next to observational and epidemiological studies, a total of 21 human trials have been evaluated in this work. Current available research is indicative, rather than evident, regarding the effectiveness of individuals' use of single nutrients with anti-inflammatory and fatigue-reducing effects. In contrast, clinical studies demonstrate that a balanced diet with whole grains high in fibers, polyphenol-rich vegetables, and omega-3 fatty acid-rich foods might be able to improve disease-related fatigue symptoms. Nonetheless, further research is needed to clarify conflicting results in the literature and substantiate the promising results from human trials on fatigue.
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http://dx.doi.org/10.3390/nu11102315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6835556PMC
September 2019

Problematic drinking in the old and its association with muscle mass and muscle function in type II diabetes.

Sci Rep 2019 08 19;9(1):12005. Epub 2019 Aug 19.

Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Lipid Clinic at the Interdisciplinary Metabolism Center, Berlin, Germany.

Problematic drinking behavior is common in the old and negative consequences of hypoglycemic episodes in type 2 diabetes (T2D) as a result of alcohol consumption have been described previously. Although, associations between such hypoglycemic episodes with reduced muscle mass are discussed, it is uncertain if problematic drinking behavior drives decline of muscle mass and/or muscle function. In the current study, we analyzed data of the Berlin Aging Study II (BASE-II) to examine the association of problematic drinking behavior with muscle mass and grip strength in T2D. Cross-sectional data of 1451 old BASE-II participants (51.6% women; 60-84 years old) were analyzed. Problematic drinking behavior was assessed using the Alcohol Use Identification Test (AUDIT). Muscle mass was measured using dual energy X-ray absorptiometry (DXA), grip strength using a Smedley dynamometer. Adjusted regression models were calculated to assess the association of problematic drinking with muscle mass and grip strength. Problematic drinking was evident in 11.2% of BASE-II participants and in 12.5% of BASE-II participants diabetes was evident. In the fully adjusted model (adjusted for age, trunk fat mass, HbA1c, antidiabetic medication, TSH, CRP, testosterone, physical inactivity, depression (GDS-score), morbidities, smoking status and total energy intake/day, we found a statistically significant association between problematic drinking and muscle mass (β-3.7, SE: 1.3, R 0.481, partial eta square 0.166, observed power 0.816, p-value 0.005) and grip strength (β-8.1, SE: 3.3, R 0.222, partial eta square 0.134, observed power 0.670, p-value 0.018) in old diabetic men. These associations were not evident in women and subjects without T2D. Problematic drinking behavior was associated with lower muscle mass and grip strength in old men with diabetes. This topic should be addressed in these subjects as they could be at increased risk for early functional decline, sarcopenia or frailty.
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http://dx.doi.org/10.1038/s41598-019-47787-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6700201PMC
August 2019

Clinical Value of Muscle Mass Assessment in Clinical Conditions Associated with Malnutrition.

J Clin Med 2019 Jul 17;8(7). Epub 2019 Jul 17.

Clinical Nutrition, Geneva University Hospital, 1205 Geneva, Switzerland.

Malnutrition results from a reduction of food intake or an alteration of nutrient assimilation and leads to decreased lean mass. Strong evidence shows that malnutrition associated with loss of muscle mass negatively impacts clinical outcomes. The preservation or improvement of muscle mass represents a challenge. This review aims to (1) describe current methods to assess muscle mass in clinical practice, (2) describe the associations between muscle mass and clinical outcomes, and (3) describe the impact of interventions aiming at increasing muscle mass on clinical outcomes. It highlights the importance of assessing muscle mass as part of the screening and the follow-up of malnutrition in clinical practice.
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http://dx.doi.org/10.3390/jcm8071040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6678556PMC
July 2019

Editorial: From the macro to the micro: assessment of nutritional and metabolic status.

Curr Opin Clin Nutr Metab Care 2019 09;22(5):321-322

Departments of Chemistry and Medicine, University of Vermont, Burlington, Vermont, USA.

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http://dx.doi.org/10.1097/MCO.0000000000000590DOI Listing
September 2019

Economic Challenges in Nutritional Management.

J Clin Med 2019 Jul 10;8(7). Epub 2019 Jul 10.

Department for Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, and University of Bern, 3010 Bern, Switzerland.

Disease-related malnutrition (DRM) is a highly prevalent independent risk and cost factor with significant influence on mortality, morbidity, length of hospital stay (LOS), functional impairment and quality of life. The aim of our research was to estimate the economic impact of the introduction of routinely performed nutritional screening (NS) in a tertiary hospital, with subsequent nutritional interventions (NI) in patients with potential or manifest DRM. Economic impact analysis of natural detection of inpatients at risk and estimation of the change in economic activity after the implementation of a systematic NS were performed. The reference population for natural detection of DRM is about 20,000 inpatients per year. Based on current data, DRM prevalence is estimated at 20%, so 4000 patients with potential and manifest DRM should be detected. The NI costs were estimated at CHF 0.693 million, with savings of CHF 1.582 million (LOS reduction) and CHF 0.806 million in additional revenue (SwissDRG system). Thus, the introduction of routine NS generates additional costs of CHF 1.181 million that are compensated by additional savings of CHF 2.043 million and an excess in additional revenue of CHF 2.071 million. NS with subsequent adequate nutritional intervention shows an economic potential for hospitals.
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http://dx.doi.org/10.3390/jcm8071005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6678224PMC
July 2019

Management of Malnutrition in Older Patients-Current Approaches, Evidence and Open Questions.

J Clin Med 2019 Jul 4;8(7). Epub 2019 Jul 4.

Department for Geriatric Medicine, Marien Hospital Herne-University Hospital, Ruhr-Universität Bochum, 44625 Herne, Germany.

Malnutrition is widespread in older people and represents a major geriatric syndrome with multifactorial etiology and severe consequences for health outcomes and quality of life. The aim of the present paper is to describe current approaches and evidence regarding malnutrition treatment and to highlight relevant knowledge gaps that need to be addressed. Recently published guidelines of the European Society for Clinical Nutrition and Metabolism (ESPEN) provide a summary of the available evidence and highlight the wide range of different measures that can be taken-from the identification and elimination of potential causes to enteral and parenteral nutrition-depending on the patient's abilities and needs. However, more than half of the recommendations therein are based on expert consensus because of a lack of evidence, and only three are concern patient-centred outcomes. Future research should further clarify the etiology of malnutrition and identify the most relevant causes in order to prevent malnutrition. Based on limited and partly conflicting evidence and the limitations of existing studies, it remains unclear which interventions are most effective in which patient groups, and if specific situations, diseases or etiologies of malnutrition require specific approaches. Patient-relevant outcomes such as functionality and quality of life need more attention, and research methodology should be harmonised to allow for the comparability of studies.
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http://dx.doi.org/10.3390/jcm8070974DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6678789PMC
July 2019

Development of a Model on Determinants of Malnutrition in Aged Persons: A MaNuEL Project.

Gerontol Geriatr Med 2019 Jan-Dec;5:2333721419858438. Epub 2019 Jun 21.

Vrije Universiteit Amsterdam, The Netherlands.

In older persons, the origin of malnutrition is often multifactorial with a multitude of factors involved. Presently, a common understanding about potential causes and their mode of action is lacking, and a consensus on the theoretical framework on the etiology of malnutrition does not exist. Within the European Knowledge Hub "Malnutrition in the Elderly (MaNuEL)," a model of "eterminants f alnutrition in ged ersons" (DoMAP) was developed in a multistage consensus process with live meetings and written feedback (modified Delphi process) by a multiprofessional group of 33 experts in geriatric nutrition. DoMAP consists of three triangle-shaped levels with malnutrition in the center, surrounded by the three principal conditions through which malnutrition develops in the innermost level: low intake, high requirements, and impaired nutrient bioavailability. The middle level consists of factors directly causing one of these conditions, and the outermost level contains factors indirectly causing one of the three conditions through the direct factors. The DoMAP model may contribute to a common understanding about the multitude of factors involved in the etiology of malnutrition, and about potential causative mechanisms. It may serve as basis for future research and may also be helpful in clinical routine to identify persons at increased risk of malnutrition.
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http://dx.doi.org/10.1177/2333721419858438DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6589946PMC
June 2019

Is a Single 24-hour Dietary Recall per Person Sufficient to Estimate the Population Distribution of Usual Dietary Intake?

J Nutr 2019 09;149(9):1491-1492

Department of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Nuthetal, Germany.

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http://dx.doi.org/10.1093/jn/nxz118DOI Listing
September 2019

Higher serum levels of fibroblast growth factor 21 in old patients with cachexia.

Nutrition 2019 Jul - Aug;63-64:81-86. Epub 2018 Nov 22.

Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Research Group on Geriatrics, Working Group Nutrition and Body Composition, Berlin, Germany; German Institute of Human Nutrition Potsdam - Rehbrücke, Department of Nutrition and Gerontology, Nuthetal, Germany; University of Potsdam, Institute of Nutritional Science, Nuthetal, Germany. Electronic address:

Objective: Fibroblast growth factor (FGF)21 is promptly induced by short fasting in animal models to regulate glucose and fat metabolism. Data on FGF21 in humans are inconsistent and FGF21 has not yet been investigated in old patients with cachexia, a complex syndrome characterized by inflammation and weight loss. The aim of this study was to explore the association of FGF21 with cachexia in old patients compared with their healthy counterparts.

Methods: Serum FGF21 and its inactivating enzyme fibroblast activation protein (FAP)-α were measured with enzyme-linked immunoassays. Cachexia was defined as ≥5% weight loss in the previous 3 mo and concurrent anorexia (Council on Nutrition appetite questionnaire).

Results: We included 103 patients with and without cachexia (76.9 ± 5.2 y of age) and 56 healthy controls (72.9 ± 5.9 y of age). Cachexia was present in 16.5% of patients. These patients had significantly higher total FGF21 levels than controls (952.1 ± 821.3 versus 525.2 ± 560.3 pg/mL; P = 0.012) and the lowest FGF21 levels (293.3 ± 150.9 pg/mL) were found in the control group (global P < 0.001). Although FAP-α did not differ between the three groups (global P = 0.082), bioactive FGF21 was significantly higher in patients with cachexia (global P = 0.002). Risk factor-adjusted regression analyses revealed a significant association between cachexia and total (β = 649.745 pg/mL; P < 0.001) and bioactive FGF21 (β = 393.200 pg/mL; P <0.001), independent of sex, age, and body mass index.

Conclusions: Patients with cachexia exhibited the highest FGF21 levels. Clarification is needed to determine whether this is an adaptive response to nutrient deprivation in disease-related cachexia or whether the increased FGF21 values contribute to the catabolic state.
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http://dx.doi.org/10.1016/j.nut.2018.11.004DOI Listing
September 2020

Influence of nutritional tyrosine on cognition and functional connectivity in healthy old humans.

Neuroimage 2019 06 7;193:139-145. Epub 2019 Mar 7.

University Clinic Hamburg-Eppendorf, Clinic and Policlinic for Psychiatry and Psychotherapy, Martinistraße 52, 20246, Hamburg, Germany; Max Planck Institute for Human Development, Lise Meitner Group for Environmental Neuroscience, Berlin, Germany. Electronic address:

Tyrosine is precursor for monoamine neurotransmitters such as dopamine (DA), which is one of the key neurotransmitters in the frontostriatal network and of crucial relevance for mental disorders. Recent research reported that high dose tyrosine application resulted in increased brain DA synthesis, which is consistent with the observation of positive associations between daily tyrosine intake and cognitive test performance. In the present study, we investigated the associations between working memory (WM) dependent tasks and self-reported nutritional tyrosine intake within a large group of healthy elderly humans (286 subjects) by additionally including brain functional data. We observed a negative correlation between tyrosine intake and resting-state functional connectivity (rsFC) between the striatum (putamen) and the prefrontal cortex. That is to say, we found higher rsFC in individuals consuming less tyrosine per day. At the same time, this increasedrsFC or hyperconnectivity was associated with lower WM performance. These findings suggest that lower or insufficient supply of tyrosine might result in dysfunctional connectivity between striatal and frontal regions leading to lower WM capacity in healthy elderly humans.
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http://dx.doi.org/10.1016/j.neuroimage.2019.03.005DOI Listing
June 2019

Sex-specific differences in the association of vitamin D with low lean mass and frailty: Results from the Berlin Aging Study II.

Nutrition 2019 06 23;62:1-6. Epub 2018 Nov 23.

Research Group on Geriatrics, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; German Institute for Human Nutrition Potsdam-Rehbrücke, Department of Nutrition and Gerontology, Nuthetal, Germany; University of Potsdam, Institute of Nutritional Science, Nuthetal, Germany.

Background: Sex-specific differences in factors associated with aging and lifespan, such as sarcopenia and disease development, are increasingly recognized. The study aims to assess sex-specific aspects of the association between vitamin D insufficiency and low lean mass as well as between vitamin D insufficiency and the frailty phenotype.

Methods: A total of 1102 participants (51% women) from the Berlin Aging Study II were included in this cross-sectional study. Vitamin D insufficiency was defined as a 25(OH)D level <50 nmol/L. Lean mass was assessed with dual-energy x-ray absorptiometry and corrected by body mass index. Low lean mass was defined according to the Foundations for the National Institutes of Health Sarcopenia Project criteria (appendicular lean mass/body mass index <0.789 in men and <0.512 in women) and frailty defined according to the Fried criteria.

Results: In a risk factor-adjusted analysis, the association of vitamin D insufficiency was significantly influenced by sex (P for interaction < 0.001). Men with vitamin D insufficiency had 1.8 times higher odds of having low lean mass, with no association between vitamin D insufficiency and low lean mass in women. Participants with vitamin D insufficiency had 1.5 higher odds of being prefrail/frail with no significant effect modification by sex.

Conclusions: We found notable sex-specific differences in the association of vitamin D insufficiency with low lean mass but not of vitamin D insufficiency with frailty. Vitamin D might play a relevant role in the loss of lean mass in men but not women and might be a biological marker of an unfavorable aging process associated with early development of frailty regardless of sex.
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http://dx.doi.org/10.1016/j.nut.2018.11.020DOI Listing
June 2019

Tri-country translation, cultural adaptation, and validity confirmation of the Scored Patient-Generated Subjective Global Assessment.

Support Care Cancer 2019 Sep 25;27(9):3499-3507. Epub 2019 Jan 25.

Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, Netherlands.

Purpose: The Scored Patient-Generated Subjective Global Assessment (PG-SGA) is the only malnutrition (risk) assessment tool that combines patient-generated measures with professional-generated (medical) factors. We aimed to apply international standards to produce a high quality, validated, translation and cultural adaptation of the original PG-SGA for the Austrian, German, and Swiss setting.

Methods: Analogue to methodology used for the Dutch, Portuguese, and Thai versions of PG-SGA, the ten steps of the International Society for Pharmacoeconomics and Outcomes Research's principles of good practice for translation and cultural adaptation were followed. Comprehensibility and difficulty of the translation were assessed in 103 patients and 104 healthcare professionals recruited from all three German-speaking countries. Content validity of the translation was assessed among healthcare professionals (HCP). Item and scale indices were calculated for content validity (I-CVI; S-CVI), comprehensibility (I-CI; S-CI), and difficulty (I-DI; S-DI).

Results: Patients' perceived comprehensibility and difficulty of the PG-SGA fell within the range considered to be excellent (S-CI = 0.90, S-DI = 0.90), HCP-perceived content validity (S-CVI = 0.90) was also excellent, while HCP-perceived comprehensibility fell within the high range of acceptable (S-CI = 0.87). The professional component of the PG-SGA was perceived as below acceptable (S-DI = 0.72) with the physical exam being rated the most difficult (I-DI=0.29-0.75).

Conclusions: The systematic approach resulted in a high-quality validation of the German language version of the PG-SGA, that is internationally comparable, comprehensible, easy to complete, and considered relevant for use in Austria, Germany and Switzerland.
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http://dx.doi.org/10.1007/s00520-019-4637-3DOI Listing
September 2019

Body weight changes and incidence of cachexia after stroke.

J Cachexia Sarcopenia Muscle 2019 06 24;10(3):611-620. Epub 2019 Jan 24.

BIH Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Germany.

Background: Body weight loss is a frequent complication after stroke, and its adverse effect on clinical outcome has been shown in several clinical trials. The purpose of this prospective longitudinal single-centre observational study was to investigate dynamical changes of body composition and body weight after ischemic stroke and an association with functional outcome.

Methods: Sixty-seven consecutive patients (age 69 ± 11 years, body mass index 27.0 ± 4.1 kg/m , 42% female patient, mean ± SD) with acute ischemic stroke with mild to moderate neurological deficit (National Institute of Health Stroke Scale median 4, ranged 0-12) were analysed in the acute phase (4 ± 2 days) and at 12 months (389 ± 26 days) follow-up. Body composition was examined by dual energy X-ray absorptiometry. Cachexia was defined according to the consensus definition by body weight loss ≥5% within 1 year and additional clinical signs. Lean tissue wasting was considered if a ratio of upper and lower limbs lean mass sum to squared height (kg/m ) was ≤5.45 kg/m for female patient and ≤7.25 kg/m for male patient.

Results: According to the body weight changes after 12 months, 42 (63%) patients had weight gain or stable weight, 11 (16%) patients had moderate weight loss, and 14 (21%) patients became cachectic. A relative decline of 19% of fat tissue and 6.5% of lean tissue was observed in cachectic patients, while no changes of lean tissue were observed in non-cachectic patients after 12 months. The modified Rankin Scale was 48% higher (2.1 ± 1.6, P < 0.05), Barthel Index was 22% lower (71 ± 39, P < 0.01), and handgrip strength was 34% lower (21.9 ± 13.0, P < 0.05) in cachectic compared to non-cachectic patients after 12 months. The low physical performance if defined by Barthel Index <60 points was linked to the lean tissue wasting (OR 44.8, P < 0.01), presence of cachexia (OR 20.8, P < 0.01), and low body mass index <25 kg/m (OR 11.5, P < 0.05). After adjustment for cofounders, lean tissue wasting remained independently associated with the low physical performance at 12 months follow-up (OR 137.9, P < 0.05).

Conclusions: In this cohort study, every fifth patient with ischemic stroke fulfilled the criteria of cachexia within 12 months after index event. The incidence of cachexia was 21%. Cachectic patients showed the lowest functional and physical capacity.
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http://dx.doi.org/10.1002/jcsm.12400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6596391PMC
June 2019