Elsevier

Clinical Nutrition

Volume 36, Issue 6, December 2017, Pages 1661-1668
Clinical Nutrition

Original article
Nutritional assessment using stable isotope ratios of carbon and nitrogen in the scalp hair of geriatric patients who received enteral and parenteral nutrition formulas

https://doi.org/10.1016/j.clnu.2016.10.017Get rights and content

Summary

Background & aims

The δ13C and δ15N values in the scalp hair of geriatric patients in Japan who received the enteral or parenteral nutrition formula were measured to assess nutritional status.

Methods

The relations among δ13C, δ15N, calorie intake, BMI, albumin concentration, total cholesterol (T-CHO) and geriatric nutritional risk index (GNRI) in the patients were investigated. Furthermore, the enrichment of δ13C and δ15N from the nutrients to the hair was investigated.

Results

The δ13C values in the hair of patients who received enteral nutrition decreased with decreases in the calories received, while the δ15N values increased, suggesting malnutrition in some patients with a low calorie intake due to a negative nitrogen balance. The distribution of patients with a low calorie intake (below 20 kcal/kg/day) when δ13C was plotted against δ15N differed from that of control subjects, but the distribution of patients with a high calorie intake (above 20 kcal/kg/day) was similar to that of control subjects. No significant differences were observed in BMI, albumin concentration, T-CHO or GNRI between the low and high calorie groups. The enrichment of δ13C and δ15N from the enteral nutrients to the hair were inversely correlated with the δ13C and δ15N in the enteral nutrients. The enrichment levels of δ13C and δ15N tended to be higher and lower, respectively, in the high calorie group. On the other hand, the δ13C and δ15N values in the hair of patients who received parenteral nutrition were higher and lower than those in the control subjects and in the patients who received enteral nutrition, respectively, reflecting the higher δ13C and lower δ15N contents of the parenteral nutrients.

Conclusions

The δ13C and δ15N values in the hair of patients who received enteral nutrition may be effective indicators for evaluating the long-term nutritional status of geriatric patients. A calorie intake of 20 kcal/kg/day may be a cut-off value for malnutrition in Japanese geriatric patients receiving enteral nutrition. However, caution is necessary when dealing with patients switching from parental nutrition as parenteral nutrition resulted in different changes in δ13C and δ15N. The enrichment levels of δ13C and δ15N from the enteral nutrients to the hair may be inversely correlated with the δ13C and δ15N values of enteral nutrients and vary according to the calorie intake.

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.).

References (24)

  • J.H.J. McCutchan et al.

    Variation in trophic sift for stable isotope ratios of carbon, nitrogen, and sulfur

    OIKOS

    (2003)
  • T. Endo et al.

    Relationships among mercury concentration, and stable isotope ratios of carbon and nitrogen in the scalp hair of residents from seven countries: effects of marine fish and C4 plants consumption

    PLoS One

    (2015)
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