Objective: Explore patterns of post-malnutrition growth (PMGr) during and after treatment for severe malnutrition, and describe associations with survival and non-communicable disease (NCD) risk seven years post-treatment. Design: Six indicators of PMGr were derived based on a variety of timepoints, weight, weight-for-age z-score (WAZ) and height-for-age z-score (HAZ). Three categorisation methods included: no categorisation, quintiles, and latent class analysis (LCA). Associations with mortality risk, and seven NCD indicators were analysed. Setting: Secondary data from Blantyre, Malawi between 2006 and 2014. Participants: A cohort of 1024 children treated for severe malnutrition (weight-for-length z-score <70% median and/or MUAC<110 mm and/or bilateral oedema) at aged 5 to 168 months Results: Faster weight gain during treatment (g/day) and after treatment (g/kg/day) were associated with lower risk of death (aOR 0.99, 95%CI 0.99 to 1.00; and aOR 0.91, 95% CI 0.87 to 0.94 respectively). In survivors (mean age 9 years), it was associated with greater hand grip strength (0.02, 95%CI 0.00 to 0.03) and larger HAZ (6.62, 95%CI 1.31 to 11.9), both indicators of better health. However, faster weight gain was also associated with increased waist:hip ratio (0.02, 95%CI 0.01 to 0.03), an indicator of later life NCD risk. The clearest patterns of association were seen when defining PMGr based on weight gain in g/day during treatment and using the LCA method to describe growth patterns. Weight deficit at admission was a major confounder. Conclusions: A complex pattern of benefits and risks is associated with faster PMGr. Both initial weight deficit and rate of weight gain have important implications for future health.
Background: Nutritional rehabilitation during severe malnutrition (SM) aims to rapidly restore body size and minimize poor short-term outcomes. We hypothesized that too rapid weight gain during and after treatment might however predispose to cardiometabolic risk in adult life. Methods: Weight and height during hospitalization and one year post-hospitalization were abstracted from hospital records of children who survived SM. Six definitions of post-malnutrition weight gain/growth were analysed as continuous variables, quintiles and latent classes in age-sex and minimum weight-for-age z-scores-adjusted regression models against adult anthropometry, body composition (DEXA), blood pressure, blood glucose, insulin and lipids. Results: 60% of 278 participants were male, mean (SD) age 28.2 (7.7) years, mean (SD) BMI 23.6 (5.2) kg/m2. Mean admission age for SM was 10.9 months (range 0.3-36.3 months) and 207/270 (77%) were wasted (weight-for-height z-score<-2). During childhood, mean rehabilitation weight gain (SD) was 10.1(3.8) g/kg/day and 0.8(0.5) g/kg/day in the first year post-hospitalization. Rehabilitation weight gain >12.9 g/kg/day was associated with higher adult BMI (difference=0.5kg/m2, 95%CI: 0.1-0.9, p = 0.02), waist circumference (difference=1.4cm, 95%CI: 0.4-2.4, p=0.005), fat mass (difference = 1.1kg, 95%CI: 0.2-2, p=0.02), fat mass index (difference=0.32, 95%CI: -0.0001-0, p=0.05), and android fat mass (difference=0.09 kg, 95%CI: 0.01-0.2, p=0.03). Rehabilitation (g/month) and post-hospitalization (g/kg/month) weight gain were associated with greater lean mass (difference = 0.7 kg, 95% CI: 0.1, 1.3, p = 0.02) (difference=1.3kg, 95% CI: 0.3-2.4, p=0.015) respectively. Conclusion: Rehabilitation weight gain exceeding 13g/kg/day was associated with adult adiposity in young, normal-weight adult SM survivors. This raises questions around existing malnutrition weight gain targets and warrants further studies exploring optimal post-malnutrition growth.
The outcome of warfarin therapy varies among individuals due to factors such as genetics, age, ethnicity, diet and weight which have been shown to have varying impact on therapeutic anticoagulation [3-10]. Although many studies have reported benefits of the use of these parameters to determine warfarin doses, clinically guided management still relies heavily on monitoring International Normalized Ratio (INR). The primary objective of the study was to examine the prevalence of therapeutic anticoagulation with warfarin among patients registered in a setting where clinically guided management is the only available system for monitoring warfarin efficacy. The secondary objectives of the study include an assessment of the differences between subjects that are within the target INR range (therapeutic anticoagulation) and those subjects outside the target INR (non-therapeutic anticoagulation). Methods This was a cross-sectional, observational, convenience sample study of adults (at least 18 years of age) on warfarin maintenance therapy recruited from the University Hospital of the West Indies Cardiology Clinic in the two time periods (January 2014-May 2014 and February 2015-October 2015). Inclusion criteria also required subjects to be warfarin for more than one month and self-report of good compliance. Informed consent guidelines were followed and all subjects recruited in this study consented to participate. After Informed Consent was obtained, information recorded included daily dose, date of initiation, and indication for warfarin therapy. Also recorded for each subjects was age, weight, height, gender, ethnicity and concomitantly administered drugs. INR assessment A single sample of one drop (≥ 8µL) of capillary blood from each patient, obtained by pinprick was used to obtain INR
BackgroundNutritional rehabilitation during severe acute malnutrition (SAM) aims to quickly restore a healthy body weight, but rapid weight gain has been associated with later cardiovascular risk. We hypothesized that faster weight gain during SAM rehabilitation and post-hospitalization is associated with liver fat in adult survivors.MethodJamaican adult survivors of childhood SAM underwent abdominal CT scan to estimate liver fat as mean liver attenuation (MLA) and liver spleen ratio (L/S). Birth weight (BW) and anthropometry measured during, and post-hospitalization were abstracted from admission records.ResultsWe studied 42 marasmus survivors (MRs) and 40 kwashiorkor survivors (KWs). MRs had a lower mean BW (SD) 2.5 (0.8) vs 3.0 (0.7) kg; p=0.01) and were more wasted (p<0.001) and stunted (p=0.03) than KWs on admission to hospital. MRs and KWs had similar rates of rehabilitation weight gain, which was inversely associated with MLA among all survivors of SM (r=-0.246, p=0.029), but only in MRs when assessed by diagnosis (r= -0.449, p=0.004). The association between rehabilitation weight gain and adult liver fat in MRs was not altered by BW, admission wasting or stunting. In KWs, post-hospitalization height gain was inversely associated with MLA (difference = -0.64, 95%CI: -0.64 to -0.13; p=0.006).ConclusionsFaster rehabilitation weight gain is associated with liver fat in adult survivors of childhood severe acute malnutrition. The finding that BW did not influence these outcomes may reflect the timing of the nutritional insult in utero. Target weight gain during nutritional rehabilitation may need to be lowered to optimize long-term outcomes in these children.
Background: Rapid catch-up growth after prenatal undernutrition is associated with increased risk of non-communicable diseases (NCDs) in high-income countries. Severe malnutrition treatment programmes in low- and middle-income countries promote rapid post-malnutrition growth (PMGr) as desirable. Our aim was to explore patterns of PMGr during and in the year following treatment, and describe associations with survival and NCD risk seven years post-treatment. Methods: Secondary data analysis from a cohort of children treated for severe malnutrition in Malawi in 2006/7. Six definitions of PMGr were derived based on a variety of timepoints, weight, weight-for-age z-score (WAZ) and height-for-age z-score (HAZ). Three categorisation methods included: no categorisation, quintiles, and latent class analysis (LCA). Associations with mortality risk, and with eight NCD indicators were analysed visually using scatter plots and boxplots, and statistically using simple and multivariable linear regression. Findings: Faster weight gain was associated with lower risk of death (g/day during treatment aOR 0.99, 95%CI 0.99 to 1.00, p=0.04; after treatment g/kg/month aOR 0.91, 95% CI 0.87 to 0.94, p<0.001). In survivors, it was associated with greater hand grip strength in some instances (g/day during treatment 0.02, 95%CI 0.00 to 0.03, p=0.007) and larger HAZ 7-years post-discharge (adjusted Δ WAZ per day during treatment 6.62, 95%CI 1.31 to 11.9, p=0.02), both indicators of better health. However, faster weight gain in treatment was also associated with increased waist:hip ratio (adjusted g/day during treatment 0.02, 95%CI 0.01 to 0.03, p=0.003), a key indicator of later life NCD risk. The clearest patterns of association were seen when defining PMGr based on weight gain in g/day during treatment, and using the LCA method to describe growth patterns. Weight deficit at admission was a major confounder. Conclusion: We found a complex pattern of benefits and risks associated with faster PMGr with a possible trade-off between short- and long-term benefits/risks. Peripheral versus visceral weight distribution in particular requires further exploration. Both initial weight deficit and rate of weight gain have important implications for future health. Because conclusions from observational studies can go only so far, future randomised intervention trials are needed.
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