Lymphedema and vitamins

Lymphedema and vitamins

**Editor's note: This is an interesting article, even though it dates back to 1971.  Written by the Földi clinic, so thought it worth sharing.** 

Ethel Földi-Borcsok and M. Földi - Lymphödem

In 1971, the unexpected fact has been described (1) that surgically induced acute experimental lymphedema in the rat flourished with the usual laboratory diet rich in
vitamins, can be treated successfully by the administration of various vitamins, e.g., pyndoxine, pantothenic acid, and particularly, a highly active representative of the vitamin P family,2 coumarin (5 , 6-benzo-a-pyron). These data, obtained by means of plethysmographic assessment of the volume of lymphedema, were confirmed by histology.

Based on these results, the question has to be raised whether an inadequate supplying of the organism with vitamins would aggravate lymphedema. After having obtained an affirmative answer to this question, therapeutic trials were performed in avitaminotic
lymphedematous animals. 

Material and methods

Experiments were performed in 150 male Wistar rats (body weights given in Fig. 1). The animals were divided into three groups.

Group 1

Group 1 comprised rats fed ad libitum an artificial diet rich in vitamins (Table 1). On the 56th day, these animals were divided into five subgroups. 

Subgroup 1.1 (n = 10). From the 56th to the 63rd day, the rats were given daily ip injections of saline, 10 mI/kg body wt. On the 60th day, the rats were anesthetized with nembutal (50 mg/kg ip). Preoperative volume of the neck and head was measured by electronic plethysmography by means of the apparatus constructed by Bundschuh (Griesheim, W. Germany). This was followed by a radical cervical lymphatic blockage. From a midline incision reaching from the mandibula to the sternum, lymph nodes were carefully prepared and
ligated. Plethysmographic measurements were repeated on the 63rd day.

Subgroup 1.2 (n = 10). In this subgroup, the procedure was the same as in subgroup 1.1, with
just one difference. Instead of saline, the rats were treated with the following vitamins in milligrams per kilogram body weight: vitamin B1, 40; lactoflavin, 23; niamid, 160; pyridoxine, 16; pantothenic acid, 240; biotin, 2 and cyanocobalamin, 80 pg/kg body weight.

Subgroup 1.3 (n 10). Procedure was the same as in subgroups 1.1 and 1.2 with one difference; i.e., the animals were treated with 25 mg/kg coumarin
(5 , 6-benzo-alpha-pyron). Subgroup 1.4 (,z 10). Procedure differed from that used in subgroups 1.1, 1.2, and 1.3 in one respect; the rats were treated with 500 mg/kg tnhydroxy-ethyl-rutin. Subgroup 1.5 (n 10). In this subgroup, the same procedure was followed as with subgroup 1.1 except that instead of a cervical lymphatic blockage, only a sham operation was performed.

Group 2

Rats were fed a diet (ad libitum) that was poor in B-complex vitamins (Table 1). On the 35th day, the rats were divided into five subgroups. (This day was chosen instead of the 56th because vitamin B deficiency was already marked and the state of the rats deteriorated rapidly.)

Subgroup 2.1 (n 10). From the 35th to the 42nd day, the rats were given daily ip injections of saline. On the 39th day, they were treated as those in subgroup 1 . 1 . Plethysmographic measurements were repeated on the 42nd day. Subgroup 2.2 (n 10). In this subgroup, procedure was the same as in subgroup 2.1, with one exception. Instead of saline, the rats were treated with the same vitamins as those in subgroup 1.2. Subgroup 2.3 (n 10). The rats in this group were treated with coumarin; otherwise the procedure was the same as in subgroup 2.1 and 2.2.

Subgroup 2.4 (n = 10). Our procedure differed from that used in subgroups 2.1, 2.2, and 2.3 in one respect, these rats were treated with trihydroxyethyl-rutin. Subgroup 2.5 (n = 10). In this subgroup, the procedure was the same as in subgroup 2.1 except that instead of a lymphatic blockage, only a sham operation was performed.

Group 3

Rats in this group were fed the Sherman-LaMerCampbell diet (4), free of vitamin P but supplemented with ascorbic acid (Table 1). This group..... 

Complete Text with charts:

American Journal of Clinical Nutrition

Protein-Loosing Entropathy Induced by Unique Combination of CMV and HP in an Immunocompetent Patient.

2012

Chen S, Lalazar G, Barak O, Adar T, Doviner V, Mizrahi M.

Source

Internal Medicine A, Liver Unit, Hebrew University-Hadassah Medical Organization, P.O. Box 12000, Jerusalem IL 91120, Israel.

Abstract

Protein-losing gastroenteropathies are characterized by an excessive loss of serum proteins into the gastrointestinal tract, resulting in hypoproteinemia (detected as hypoalbuminemia), edema, and, in some cases, pleural and pericardial effusions. Protein-losing gastroenteropathies can be caused by a diverse group of disorders and should be suspected in a patient with hypoproteinemia in whom other causes, such as malnutrition, proteinuria, and impaired liver protein synthesis, have been excluded. In this paper, we present a case of protein-losing enteropathy in a 22-year-old immunocompetent male with a coinfection of CMV and Hp.  

Introduction:

Protein-losing gastroenteropathies can be caused by a diverse group of disorders, in which an increase in intestinal leakage of plasma proteins occurs. This leakage can occur via either mucosal injury or increased lymphatic pressure in the gut. Laboratory findings include reduced serum concentrations of albumin, gamma globulins, fibrinogen, transferrin, and ceruloplasmin. The hypoalbuminemia may lead to edema of the lower extremities.

A variety of benign and malignant conditions can be associated with protein-losing gastroenteropathy, for example, IBD and gastrointestinal malignancies. However, in otherwise healthy patients, the role of CMV in the pathogenesis has been suggested. A gastric biopsy in a few reported cases demonstrated the presence of CMV. However, most of these patients were children who had a typical benign and transient course and required only supportive therapy. Around 90 cases of gastrointestinal involvement were reported in healthy adult patients, the great majority with colonic involvement, among them none had coinfection with Hp. We describe a case of erosive gastritis with significant protein-loss, admitted to our department for evaluation because of vomiting and abdominal pain. Gastric-mucosal biopsy revealed morphological evidence of both CMV and Hp infection.

**Editor's note: Many lymphedema patients also have lymphangiectasia, which is a protein-loosing entropathy.  One complication is the disruption of the lymphatic processes of the intestine. This in turns contributes to over all edema, processing of fat and proteins.  Because of this,. I have included this.**

Full Text Report:

NIH-Case Reports

Nutrient Intake, Peripheral Edema, and Weight Change in Elderly Recuperative Care Patients.

Nov 2012

Sullivan DH, Johnson LE, Dennis RA, Roberson PK, Garner KK, Padala PR, Padala KP, Bopp MM.

Source

Geriatric Research Education and Clinical Center (Building 170, 3J/NLR), Central Arkansas Veterans Healthcare System, 4300W 7 Street, Little Rock, AR 72205. SullivanDennisH@uams.edu.

Abstract

BACKGROUND:

It is unclear whether serial measures of body weight are valid indicators of nutritional status in older patients recovering from illness.

OBJECTIVES: Investigate the relative influence of nutrient intake and changes in peripheral edema on weight change.

METHODS:

A prospective cohort study of 404 older men (mean age = 78.7±7.5 years) admitted to a transitional care unit of a Department of Veterans Affairs nursing home. Body weight and several indicators of lower extremity edema were measured at both unit admission and discharge. Complete nutrient intake assessments were performed daily.

RESULTS:

Over a median length of stay of 23 days (interquartile range: 15-41 days), 216 (53%) participants gained or lost more than or equal to 2.5% of their body weight. Two hundred eighty-two (70%) participants had recognizable lower extremity pitting edema at admission and/or discharge. The amount of weight change was strongly and positively correlated with multiple indicators of both nutrient intake and the change in the amount of peripheral edema. By multivariable analysis, the strongest predictor of weight change was maximal calf circumference change (partial R(2) = .35, followed by average daily energy intake (partial R(2) = .14, , and the interaction of energy intake by time (partial R(2) = .02. 

CONCLUSIONS:

Many older patients either gain or lose a significant amount of weight after admission to a transitional care unit. Because of the apparent high prevalence of co-occurring changes in total body water, the weight changes do not necessarily represent changes in nutritional status. Although repeat calf circumference measurements may provide some indication as to how much of the weight change is due to changes in body water, there is currently no viable alternative to monitoring the nutrient intake of older recuperative care patients in order to ensure that their nutrient needs are being met.

Oxford Journals

Nutritional and cultural aspects of the mediterranean diet.

Jun 2012

Serra-Majem L, Bach-Faig A, Raidó-Quintana B.

Source

Mediterranean Diet Foundation, Barcelona, Spain, and University of Las Palmas de Gran Canaria, Department of ClinicalSciences, Las Palmas de Gran Canaria, Spain.

Abstract 

The recent recognition by United Nations Educational, Scientific and Cultural Organization (UNESCO) of the Mediterranean diet as an Intangible Cultural Heritage of Humanity reinforces, together with the scientific evidence, the Mediterranean diet as a cultural and health model. The Mediterranean diet has numerous beneficial effects on among others the immune system, against allergies, on the psyche, or even on quality of life, topics that are currently fields of research. The Mediterranean diet has an international projection; it is regarded as the healthiest and the most sustainable eating pattern on the planet and is a key player in the public health nutrition field globally, but especially in the Mediterranean area. Moreover, this ancient cultural heritage should be preserved and promoted from different areas: public health, agriculture, culture, politics, and economic development.

PubMed

What foods are u.s. supermarkets promoting? A content analysis of supermarket sales circulars.

Dec 2012

Martin-Biggers J, Yorkin M, Aljallad C, Ciecierski C, Akhabue I, McKinley J, Hernandez K, Yablonsky C, Jackson R, Quick V, Byrd-Bredbenner C.

Source

26 Nichol Avenue, Nutritional Sciences Department, Rutgers, The State University of New Jersey, New Brunswick, NJ 08901, USA. Electronic address: jmartin@aesop.rutgers.edu.

Abstract

This study compared the types of foods advertised in supermarket newspaper circulars across geographic region (U.S. Census regions: northeast [n=9], midwest [n=15], south [n=14], and west [n=13]), obesity-rate region (i.e., states with CDC adult obesity rates of <25% [n=14], 25 to <30% [n=24], and ⩾30% [n=13]), and with MyPlate recommendations. All food advertisements on the first page of each circular were measured (±0.12-inch) to determine the proportion of space occupied and categorized according to food group. Overall, ⩾50% of the front page of supermarket sales circulars was devoted to protein foods and grains; fruits, vegetables, and dairy, combined, were allocated only about 25% of the front page. The southern geographic region and the highest obesity-rate region both devoted significantly more advertising space to sweets, particularly sugar-sweetened beverages. The lowest obesity-rate region and western geographic region allocated the most space to fruits. Vegetables were allocated the least space in the western geographic region. Grains were the only food group represented in ads in proportions approximately equal to amounts depicted in the MyPlate icon. Protein foods exceeded and fruits, dairy, and vegetables fell below comparable MyPlate proportional areas. Findings suggest supermarket ads do not consistently emphasize foods that support healthy weight and MyPlate recommendations. More research is needed to determine how supermarket newspaper circulars can be used to promote healthy dietary patterns.

Elsevier

Malnutrition and quality of life in older people: a systematic review and meta-analysis.

Dec 2012

**Editor's note: As life spans increase and baby boomers rapidly approaching retirement age, the elderly represent an unheard from and almost invisible class of lymphedema patients.  Many times, their lymphedema is not treated due to their age or comorbidities associated with lymphedema.  Also, with more and more elderly choosing to live alone, their attention to diet falters, and may in fact be based on their financial resources or even in their ability to prepare food.  As a result, many become malnourished and have a greatly reduced quality of life. Attention needs to focus on this issue and intervention needs to be provided Pat O'Connor**

Rasheed S, Woods RT.

Source

Department of Nutrition & Dietetics, Betsi Cadwaladr University Health Board, Bangor, UK. Electronic address: solah.rasheed@wales.nhs.uk.

Abstract

Although the effects of malnutrition on morbidity and mortality of older people is well established, there has been little work done to investigate the relationship between malnutrition and quality of life(QoL) in this population. In order to facilitate further research and to aggregate existing evidence into a clear overview, a systematic review was conducted. The objective was to identify the literature on the topic, review the findings systematically, and assess the association between nutritional statusand QoL. MEDLINE, EMBASE, CINAHL and Web of Science were searched for relevant studies published up to April 2011. 

References within identified studies also searched. The primary author extracted all data using a purpose-built form, and evaluated the quality of the studies using a published checklist. A second reviewer checked a random sample of articles independently. Evidence in the current review comes from both cohort studies and intervention trials. Results from the former suggested that individuals with malnutrition are more likely to experience poor QoL (OR: 2.85; 95% CI: 2.20 - 3.70, p<0.001). 

Consistent with this, interventions designed to improve nutritional status can also lead to significant improvements in QoL, both physical (standard mean difference 0.23, CI: 0.08 to 0.38, p=0.002) and mental aspects (standard mean difference 0.24, CI: 0.11 to 0.36, p<0.001). 

However, the results should be interpreted with caution in view of the poor quality of the included studies and the heterogeneity of methods employed in the assessment of both nutritional status and QoL. Future studies should carefully characterise their participants and use standardised parameters for nutritional and QoL assessments in order to achieve better evaluation and comparability of study results.

Elsevier

Features predicting weight loss in overweight or obese participants in a web-based intervention: randomized trial.

Dec 2012

**Editor's note:  Obesity is now rising to be the number one cause of what is referred to as secondary lymphedema.  It is absolutely essential that those of us with lymphedema maintain a healthy weight.  If we have lymphedema, being obese is like putting a gun to our head.Pat O'Connor **

Brindal E, Freyne J, Saunders I, Berkovsky S, Smith G, Noakes M.

Source

CSIRO, Food & Nutritional Sciences, Adelaide, Australia. emily.brindal@csiro.au.

Abstract

BACKGROUND:

Obesity remains a serious issue in many countries. Web-based programs offer good potential for delivery of weight loss programs. Yet, many Internet-delivered weight loss studies include support from medical or nutritional experts, and relatively little is known about purely web-based weight loss programs.

OBJECTIVE:

To determine whether supportive features and personalization in a 12-week web-based lifestyle intervention with no in-person professional contact affect retention and weight loss.

METHODS:

We assessed the effect of different features of a web-based weight loss intervention using a 12-week repeated-measures randomized parallel design. We developed 7 sites representing 3 functional groups. A national mass media promotion was used to attract overweight/obese Australian adults (based on body mass index [BMI] calculated from self-reported heights and weights). Eligible respondents (n = 8112) were randomly allocated to one of 3 functional groups: information-based (n = 183), supportive (n = 3994), or personalized-supportive (n = 3935). Both supportive sites included tools, such as a weight tracker, meal planner, and social networking platform. The personalized-supportive site included a meal planner that offered recommendations that were personalized using an algorithm based on a user's preferences for certain foods. Dietary and activity information were constant across sites, based on an existing and tested 12-week weight loss program (the Total Wellbeing Diet). Before and/or after the intervention, participants completed demographic (including self-reported weight), behavioral, and evaluation questionnaires online. Usage of the website and features was objectively recorded. All screening and data collection procedures were performed online with no face-to-face contact.

RESULTS:

Across all 3 groups, attrition was high at around 40% in the first week and 20% of the remaining participants each week. Retention was higher for the supportive sites compared to the information-based site only at week 12 (P = .01). The average number of days that each site was used varied significantly (P = .02) and was higher for the supportive site at 5.96 (SD 11.36) and personalized-supportive site at 5.50 (SD 10.35), relative to the information-based site at 3.43 (SD 4.28). In total, 435 participants provided a valid final weight at the 12-week follow-up. Intention-to-treat analyses (using multiple imputations) revealed that there were no statistically significant differences in weight loss between sites (P = .42). On average, participants lost 2.76% (SE 0.32%) of their initial body weight, with 23.7% (SE 3.7%) losing 5% or more of their initial weight. Within supportive conditions, the level of use of the online weight tracker was predictive of weight loss (model estimate = 0.34, P les then .001). Age (model estimate = 0.04, P lews then .001) and initial BMI (model estimate = -0.03, P less then .002) were associated with frequency of use of the weight tracker.

CONCLUSIONS:

Relative to a static control, inclusion of social networking features and personalized meal planning recommendations in a web-based weight loss program did not demonstrate additive effects for user weight loss or retention. These features did, however, increase the average number of days that a user engaged with the system. For users of the supportive websites, greater use of the weight tracker tool was associated with greater weight loss.

PubMed

Nutritional supplementation for stable chronic obstructive pulmonary disease.

Dec 2012

**Editor's note: Since many of those with lymphedema have corresponding breathing or lung issues, I have included this article for information.**

Ferreira IM, Brooks D, White J, Goldstein R.

Source

Asthma and Airways Centre, Toronto Western Hospital, 7th Floor, East Wing, 399 Bathurst Street, Toronto, Ontario, Canada.

Abstract

BACKGROUND:

Individuals with chronic obstructive pulmonary disease (COPD) and low body weight have impaired pulmonary status, reduced diaphragmatic mass, lower exercise capacity and higher mortality than those who are adequately nourished. Nutritional support may be useful for their comprehensive care.

OBJECTIVES:

To assess the impact of nutritional support on anthropometric measures, pulmonary function, respiratory and peripheral muscles strength, endurance, functional exercise capacity and health-related quality of life (HRQoL) in COPD.If benefit is demonstrated, to perform subgroup analysis to identify treatment regimens and subpopulations that demonstrate the greatest benefits.

SEARCH METHODS:

We identified randomised controlled trials (RCTs) from the Cochrane Airways Review Group Trials Register, a handsearch of abstracts presented at international meetings and consultation with experts. Searches are current to April 2012.

SELECTION CRITERIA:

Two review authors independently selected trials for inclusion, assessed risk of bias and extracted the data. Decisions were made by consensus.

DATA COLLECTION AND ANALYSIS:

We used post-treatment values when pooling the data for all outcomes, and change from baseline scores for primary outcomes. We used mean difference (MD) to pool data from studies that measured outcomes with the same measurement tool and standardised mean difference (SMD) when the outcomes were similar but the measurement tools different. We contacted authors of the primary studies for missing data.We established clinical homogeneity prior to pooling. We presented the results with 95% confidence intervals (CI) in the text and in a 'Summary of findings' table.

MAIN RESULTS:

We included 17 studies (632 participants) of at least two weeks of nutritional support. There was moderate-quality evidence (14 RCTs, 512 participants, nourished and undernourished) of no significant difference in final weight between those who received supplementation and those who did not (MD 0.69 kg; 95% CI -0.86 to 2.24). Pooled data from 11 RCTs (325 undernourished patients) found a statistically significant weight gain (MD 1.65 kg; 95% CI 0.14 to 3.16) in favour of supplementation; three RCTs (116 mixed population) found no significant difference between groups (MD -1.28 kg; 95% CI -6.27 to 3.72). However, when analysed as change from baseline, there was significant improvement with supplementation: 14 RCTs (five of which had imputed SE), MD 1.62 kg (95% CI 1.27 to 1.96 ); 11 RCTs (malnourished), MD 1.73 kg (95% CI 1.29 to 2.17) and three RCTs (mixed), MD 1.44 kg (95% CI 0.68 to 2.19).There was low-quality evidence from five RCTs (six comparisons, 287 participants) supporting a significant improvement from baseline for fat-free mass/fat-free mass index (SMD 0.57; 95% CI 0.04 to 1.09), which was larger for undernourished patients (three RCTs, 125 participants; SMD 1.08; 95% CI 0.70 to 1.47). There was no significant change from baseline noted for adequately nourished patients (one RCT, 71 participants; SMD 0.27; 95% CI -0.20 to 0.73), or for a mixed population (two RCTs, 91 participants; SMD -0.05; 95% CI -0.76 to 0.65).There was moderate-quality evidence from two RCTs (91 mixed participants) that nutritional supplementation significantly improved fat mass/fat mass index from baseline (SMD 0.90; 95% CI 0.46 to 1.33).There was low-quality evidence (eight RCTs, 294 participants) of an increase in mid-arm muscle circumference change (MAMC; MD 0.29; 95% CI 0.02 to 0.57).

There was low-quality evidence (six RCTs, 125 participants) of no significant difference in change from baseline scores for triceps measures (MD 0.54; 95% CI -0.16 to 1.24).There was low-quality evidence (five RCTs, 142 participants) of no significant difference between groups in the six-minute walk distance (MD 14.05 m; 95% CI -24.75 to 52.84), 12-minute walk distance or in shuttle walking. However, the pooled change from baseline for the six-minute walk distance was significant (MD 39.96 m; 95% CI 22.66 to 57.26).There was low-quality evidence (seven RCTs, 228 participants) that there was no significant difference between groups in the forced expiratory volume in one second (FEV(1); SMD -0.01; 95% CI -0.31 to 0.30) when measured in litres or percentage predicted.There was low-quality evidence (nine RCTs, 245 participants) of no significant between group difference in maximum inspiratory pressure (MIP; MD 3.54 cm H(2)O; 95% CI -0.90 to 7.99), but those who received supplementation had a higher maximum expiratory pressure (MEP; MD 9.55 cm H(2)O; 95% CI 2.43 to 16.68). 

For malnourished patients (seven RCTs, 189 participants), those with supplementation had significantly better MIP (MD 5.02; 95% CI 0.29 to 9.76) and MEP (MD 12.73; 95% CI 4.91 to 20.55).There was low-quality evidence (four RCTs, 130 participants) of no significant difference in HRQoL total score (SMD -0.36; 95% CI -0.77 to 0.06) when pooling results from both the St George's Respiratory Questionnaire (SGRQ) and the Chronic Respiratory Questionnaire (CRQ).Two trials (67 participants) used the SGRQ to measure individual domains of activity, impact and symptoms. At the end of treatment, the pooled total SGRQ score was both statistically and clinically significant (MD -6.55; 95% CI -11.7 to -1.41). The three RCTs (123 participants) that used the CRQ to measure the change in individual domains (dyspnoea, fatigue, emotion, mastery), found no significant difference between groups.

AUTHORS' CONCLUSIONS:

We found moderate-quality evidence that nutritional supplementation promotes significant weight gain among patients with COPD, especially if malnourished. Nourished patients may not respond to the same degree to supplemental feeding. We also found a significant change from baseline in fat-free mass index/fat-free mass, fat mass/fat mass index, MAMC (as a measure of lean body mass), six-minute walk test and a significant improvement in skinfold thickness (as measure of fat mass, end score) for all patients. In addition, there were significant improvements in respiratory muscle strength (MIP and MEP) and overall HRQoL as measured by SGRQ in malnourished patients with COPD.These results differ from previous reviews and should be considered in the management of malnourished patients with COPD.

PubMed

Nutrition for wound healing.

June 2012

Medlin S.

Source

Torbay Hospital, Torquay, Devon.

Abstract

The importance of the role of nutrition in wound healing is an area that has been widely explored over the last decade. It is well recognised that both macronutrients (protein, fat and carbohydrate) and micronutrients (vitamins, minerals and trace elements) play important parts in the healing of both chronic wounds and acute injuries. The term 'wound' encompasses many different situations from leg ulcers to laparostomy wounds. This article provides an overview of the role of different nutrients in the healing of wounds and guidance to nurses on first-line assessments, which can be used to ensure the patient is receiving adequate nutrition for successful wound healing. It will focus on commonly seen wounds in primary and secondary care but will not cover specialist wound management, such as laparostomy sites and burns, as these must always be cared for by experienced and specialist multidisciplinary teams.

Internurse