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Rapid Responses: Rapid Responses published:
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Rx for Wasting
- Hugh Mann (6 June 2009)
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Opportunistic infections confounding results?
- Alexander JK Wilkinson, Emily M. Wilkinson, and Masanja Philemon Mhezi (9 June 2009)
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Supplementary feeding can be dangerous.
- Richard G Fiddian-Green (11 June 2009)
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Beware of randomizing patients to food
- Richard A. Murphy, Susan Shepherd (8 July 2009)
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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Wasting is extreme weight loss due to diseases such as TB, AIDS, and cancer. We are so concerned about looking thin and fit, that we tend to overlook the issue of wasting. As a result, wasting has received inadequate research and therapeutic protocols. In my experience, wasting responds favorably to a diet that emphasizes organic whole milk, heavy cream, cheese, and mixed roasted nuts and seeds. If we dedicate ourselves to diet and internal health, our appearance and weight will take care of itself. Competing interests: None declared |
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Alexander JK Wilkinson, Medical physician Teule Hospital, Muheza, Tanzania, Emily M. Wilkinson, and Masanja Philemon Mhezi
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Ndekha et al. report a study on an extremely sick group of patients (HIV WHO stage III or IV or CD4 <250 and BMI < 18.5). The authors acknowledge high rates of opportunistic infections in these patients which is reflected by the very high mortality rate of 27%. In our experience, many of these infections have a considerable impact on BMI; most notably tuberculosis and oesophageal candidiasis. No attempt is mentioned to detect or control for possible differences in the rates of development of these infections between the two groups. Could the observed benefits of fortified spread over corn-soy blend be in part due to different rates of opportunistic infections or immune reconstitution inflammatory syndrome, rather than an effect of the food supplements themselves? Competing interests: None declared |
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Richard G Fiddian-Green, FRCS, FACS None
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Whilst nutrient intake is clearly a necessity in healthy individuals the benefit of enteral or parenteral feeding, relative to no feeding at all, has never been clearly established in the acutely ill. It is, however, generally agreed that enteral feeding is associated with less sepsis and shorter hospital stays than parenteral feeding. The beneficial effect might, however, be due to the cathartic effect of the enteral feeds reducing the bacterial and endotoxin load in the gut. A critical issue would seem to be the state of energy metabolism in gut mucosa. If it is deficient enteral feeds can make it worse and have been complicated by perforation of the gut. Premature babies are an example, premature feeding on occasion prepitating the development of NEC. Hence the suggestion that the energy status of the gut mucosa must be restored to normality before feeding in introduced. I see no reason why these principles should not apply in wasted adults starting antiretroviral therapy in Malawi. Competing interests: None declared |
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Richard A. Murphy, Medical Department Medecins Sans Frontieres / Doctors Without Borders USA, Susan Shepherd
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I commend MacDonald and colleagues for conducting an important clinical trial of two supplementary feeding strategies among patients with advanced HIV and wasting in southern Africa. But I dispute their conclusion that the "results highlight the need for a randomised controlled trial" of supplementary food compared to none in the same patient population. In inpoverished setting such as Malawi, where a significant proportion of household resources are spent on food, randomizing a patient to supplementary feeding is tantamount to providing significant additional family income. To temporarily elevate the socioeconomic status of one group - and not the other - would not allow investigators to isolate the effect of a supplementary feeding strategy and would be difficult to justify to local communities whose involvement is essential. Competing interests: None declared |
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