Original articleNutritional assessment using stable isotope ratios of carbon and nitrogen in the scalp hair of geriatric patients who received enteral and parenteral nutrition formulas
Introduction
Terrestrial plants following the C3 photosynthesis cycle show significantly depleted 13C values (about −26‰) compared to C4 plants (about −13‰) [1], and these form the base of the terrestrial food web (Fig. 1). A large amount of basic human food as well as feed for domestic animals is derived from C3 plants (wheat, barley, soy, potatoes, rice, beans, sugar beet, grass, etc.), although a few species of C4 plants (maize, sugar cane, millet, etc.) are dominant in large regions. Recently, not only sugars and bioethanol but also many amino acids have been produced from C4 plants [2].
The stable isotope ratio of nitrogen (δ15N) is used to estimate the trophic level of a food chain, while the stable isotope ratio of carbon (δ13C) is used to estimate the relative contribution to the diet of potential primary sources [1]. Many researchers have reported high levels of δ15N in the muscle of marine mammals and predatory fish, reflecting their high trophic positions [3], [4], [5] (Fig. 1), and in the scalp hair of heavy fish-eaters and marine mammal-eaters [6], [7]. Furthermore, δ13C and δ15N in the scalp hair are used to assess nutritional and metabolic status, food supply and as a diagnostic tool [6], [8], [9], [10], [11], as the scalp hair can be noninvasively sampled and records the long-term history of dietary and physiological conditions in comparison with blood and urine.
BMI as well as serum albumin is widely used as convenient indicator for nutritional access. Recently, the geriatric nutritional risk index (GNRI) [12], which is calculated from the BMI and albumin, has been used to assess the nutritional status of senior patients in Japan [13], [14].
Japanese society is aging rapidly and the number of hospitalized senior patients receiving enteral or parenteral nutrition is increasing. In our pilot study [10], we assessed the nutritional status of geriatric patients receiving enteral nutrition using δ15N and δ13C values in the scalp hair, and reported that the δ15N value in the hair increased with decreases in the calorie intake, while the δ13C value decreased, and that a calorie intake of 20 kcal/kg/day may be a cut-off level for malnutrition. Interestingly, an intake of 20 kcal/kg/day is reported to be the basal metabolic energy of Japanese women at about 80 years [15]. Detailed study is necessary to confirm these noteworthy results. In this study, we investigated the relations among the δ13C and δ15N values in the scalp hair, calorie intake, BMI and serum albumin level, and GNRI for patients who received enteral nutrition. Furthermore, the δ13C and δ15N values in the hair of the patients who received parenteral nutrition were also investigated.
Section snippets
Ethic statement
This research project and associated consent procedures were approved by the Human Research Ethics Committee of the Graduate School of Pharmaceutical Sciences, Health Sciences University of Hokkaido (No. 15P004). Hair donors provided their written informed consent to participate in this study. When the donor was child or very old patient, the informed consent was obtained from a guardian. The principles of the Declaration of Helsinki were taken into consideration for each part of this study.
Sampling of scalp hair
Stable isotope ratios of carbon and nitrogen in the scalp hair of control subjects
The δ13C and δ15N values in 184 control subjects and their ages were −19.2 ± 0.6‰, 9.2 ± 0.5‰, and 45 ± 24 years (2–88 years), respectively (Table 3). As data not shown in figure, the δ13C and δ15N values of the control subjects did not correlate with age (p > 0.10).
Figure 2 shows the relationship between the δ13C and δ15N values of the control subjects, with the 95% confidence ellipsoid shown by the dotted line. A strong correlation was found between the δ13C and δ15N values of the control
Discussion
The δ13C and δ15N values of patients with a low calorie intake (17.1 ± 2.1 kcal/kg/day) were lower and higher, respectively, than those in patients with a high calorie intake (25.4 ± 4.3 kcal/kg/day) and those in the control subjects. All patients in the low calorie group were distributed in the upper-left region (outside) of the 95% confidence ellipsoid encompassing the control subjects (Fig. 3). This phenomenon with regarding δ13C and δ15N suggests a negative nitrogen balance as observed
Conclusion
The decrease in calorie intake in patients who received enteral nutrition formula led to a decrease in δ13C and an increase in δ15N, suggesting a negative nitrogen balance. An intake of 20 kcal/kg/day may be a cut-off value for malnutrition in Japanese geriatric patients aged about 80 years who receive enteral nutrition. However, BMI, albumin and T-CHO were not markedly changed with calorie intake. The δ13C and δ15N values in the hair of geriatric patients receiving long-term enteral nutrition
Statement of authorship
Drs. Kura T, Tarumi T, and Muramatsu H and Mrs. Hotta Y, Tsukagoshi K and Hayasaka M collected the scalp hair from patients. Drs. Endo T, and Kimura O and Mr. Hayasaka M collected the scalp hair from control subjects. Mr. Hayasaka M arranged the analytical data and Dr. Endo T wrote the manuscript.
Conflict of interest
Authors declare no conflict of interests.
Acknowledgments
This work was partially supported by Grants-in-Aid for Scientific Research (C) (No. 24614012 O.K. and No. 16K00863 T.E.).
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