Patients like dietitians to adopt a patient-centred approach, which might be either patient- or practitioner-led, and to take account of what they wanted from consultations, adapting these to meet their individual requirements.

Evaluation of body composition is an important part of assessing nutritional status and provides prognostically useful data and opportunity to monitor the effects of nutrition-related disease progression and nutritional intervention. The aim of this narrative review is to critically evaluate body composition methodology in adults, focusing on anthropometric variables. The variables considered include height, weight, body mass index and alternative indices, trunk measurements (waist and hip circumferences and sagittal abdominal diameter) and limb measurements (midupper arm and calf circumferences) and skinfold thickness. The importance of adhering to a defined measurement protocol, checking measurement error and the need to interpret measurements using appropriate population-specific cut-off values to identify health risks were identified. Selecting the optimum method of assessing body composition using anthropometry depends on the purpose, i.e. evaluating obesity or undernutrition, and requires practitioners to have a good understanding of both practical and theoretical limitations and to wisely interpret the results.

Accurate assessments of nutritional status are difficult to obtain in patients with cirrhosis. The aim of this study was to devise and validate a global nutritional assessment scheme for use in this patient population. Measures of body mass index (BMI) and mid-arm muscle circumference (MAMC) were combined with details of dietary intake in a semistructured, algorithmic construct to provide a nutritional assessment scheme for use in patients with cirrhosis; evaluated individuals were classified as adequately nourished, moderately malnourished (or suspected to be), or severely malnourished. There was good interobserver agreement in the nutritional categorization of 50 patients with cirrhosis (34 men, 16 women) using this scheme ( ‫؍‬ 0.79) and significant associations with the contributing objective variables-namely, BMI (Spearman's correlation r ‫؍‬ ؊0.78; P < .001) and relative MAMC (r ‫؍‬ ؊0.69; P < .001)-confirming its internal validity. There was a significant association between nutritional categorization in 20 patients with cirrhosis (10 men, 10 women) and estimates of total body protein obtained using a four-component model (r ‫؍‬ ؊0.45; P ‫؍‬ .046), confirming the external validity of the scheme. Finally, a significant association was found between poor nutritional status in 116 patients with cirrhosis (65 men, 51 women), followed for 14 to 52 months, and shorter subsequent survival (P ‫؍‬ .0005), confirming the scheme's predictive validity. In conclusion, a global assessment scheme has been devised that provides a simple, reproducible, valid, and predictive method of assessing nutritional status in patients with cirrhosis. (HEPATOLOGY 2006;44:823-835.)

Differences exist in the nutritional composition of GF and regular food. GF food is unlikely to offer healthier alternatives to regular foods, except for those who require a GF diet for medically diagnosed conditions, and it is associated with higher costs.

AL10 9AB; telephone 01707 281385; email a.madden@herts.ac.uk Role of authors:Angela Madden designed the systematic review, undertook literature searches, reviewed and summarized evidence and co-wrote the manuscript.Hilda Mulrooney undertook literature searches, reviewed and summarized evidence and co-wrote the manuscript.Selina Shah undertook literature searches and reviewed evidence. Conflicts of interests:The authors declare that they have no conflict of interests

MeasurementsPatients with cirrhosis are frequently malnourished, 1-3 and this may have a detrimental effect on outcome. 4-7 Adequate nutritional support must be provided if the outlook for these patients is to be optimized, [8][9][10][11] but this requires a knowledge of their nutrient requirements. Detailed studies have been undertaken on protein and nitrogen balance in these patients and consistent increases in their requirements clearly demonstrated. 12-15 However, there is no consensus in the data on energy expenditure, and thus energy requirements, in this patient population. [16][17][18][19][20][21][22] Plauth et al. 23 recommended that energy requirements should be determined in patients with cirrhosis by measurement of their resting energy expenditure (REE) using indirect calorimetry. They suggest, but do not advocate, that if the facilities for measurement are not available, then energy expenditure could be estimated by use of the Harris-Benedict prediction formulae. 24 However, it has been shown that these formulae may underestimate mean measured values of REE in patients with cirrhosis by up to 13%, 17,18,[25][26][27][28][29][30][31][32][33] though presently, it is unclear whether this discrepancy is equally evident in all population subgroups.A number of alternative prediction formulae are available, 34-39 but the accuracy of the REE estimates derived from these has not been studied systematically in patients with chronic liver disease. A prediction formula developed specifically for use in this patient population, which incorporated a measure of fat-free mass (FFM) derived using bioelectrical impedance analysis, has been proposed by Mü ller et al. 40 but this has not been validated.The aims of this study were, therefore: 1) to compare values for REE predicted using the Harris-Benedict, 24 Schofield, 36 Mifflin, 39 Cunningham, 35 and Owen 37,38 formulae with measured values in both patients with cirrhosis and a comparable group of healthy volunteers; 2) to compare values for REE predicted using the ''disease-specific'' Mü ller 40 formula with measured values in patients with cirrhosis; 3) to determine if the predictions made in the patients with cirrhosis are adversely affected by malnutrition, fluid retention, the etiology of the liver injury, or the degree of hepatic decompensation; and 4) to derive an equation for predicting REE in this patient population and to assess its validity. PATIENTS AND METHODSThe patient population comprised 56 men and 44 women, with a mean (range) age of 48.5 (26-71) years, with cirrhosis of varying etiology and severity. The etiology of the liver injury was determined using historical, clinical, laboratory, radiological, and histological variables, while the functional severity of the liver disease was assessed using Pugh' s modification of Child' s grading system 41 (Table 1). Fifty-nine patients were assessed as in-patients, while the remaining 41 were assessed as out-patients. All patients with alcohol-related cirrhosis had been abstinent from alcohol for periods ra...

Background

Assumptions relating to the constancy of the D(FFM) and HF(FFM) are violated in patients with cirrhosis. Thus, standard 2-CM techniques provide inaccurate body composition estimates in this patient population.