4.1.1. By Nutrition Assessment Parameters
Malnutrition prevalence depends in part on the parameters that were chosen to determine nutritional status. For example, when 50 patients with cirrhosis were assessed according to subjective global assessment (SGA), prognostic nutritional index (PNI) and handgrip strength (HG), malnutrition was diagnosed in 28% based on SGA, 18.7% by PNI and 64% by HG. HG was superior in predicting poor clinical outcome when compared with SGA and PNI . In another study, Figueiredo et al.  measured body cell mass (BCM) by isotope dilution in 69 patients awaiting liver transplantation. Patients were also evaluated based on SGA, anthropometry, HG dynamometry, laboratory tests and dual-energy X-ray absorptiometry (DXA). Only one-half of the patients in the lowest quartile of BCM were diagnosed as malnourished by SGA. BCM was correlated (although not strongly) with arm-muscle circumference (r = 0.55) and midarm muscle circumference (r = 0.48). None of the serum laboratory values (bilirubin, prothrombin time, albumin, total lymphocyte count, micronutrient levels, lipid concentrations, amino acid concentrations) were correlated with BCM. Parameters in which the lowest quartile correlated with low BCM included serum blood levels of urea nitrogen (p = 0.002) and creatinine (p = 0.01), HG (p < 0.001), bone mineral density (p < 0.001) and lean body mass by DXA (p < 0.001). When multiple logistic regression was applied to all of the assessment variables, arm-muscle circumference and HG had the greatest influence on BCM. The authors concluded that HG and arm-muscle circumference were the most sensitive markers in diagnosing BCM loss in the liver disease patient.
The prevalence of malnutrition also depends on the type of liver disease (see Table 4.3). Over 15 years ago, DiCecco et al.  evaluated the rate of malnutrition in patients undergoing liver transplantation based on diagnosis (chronic active hepatitis, primary sclerosing hepatitis, primary biliary cirrhosis and acute/subacute hepatitis) and assessment parameters (diet history, anthropometrics and biochemical measurements). They found that modest decreases in all nutrition parameters occurred in patients with chronic hepatitis. Patients with sclerosing cholangitis had the lowest mean levels of midarm muscle circumference as well as vitamin and mineral levels; however, they maintained their fat stores. Patients with primary biliary cirrhosis experienced the greatest fat and muscle loss, but maintained hepatic synthetic function.
Pattern of Malnutrition in Liver Disease
Muscle wasting Loss of fat stores synthetic function
Primary biliary cirrhosis
Primary sclerosing cholangitis
+, mild abnormalities; ++, moderate abnormalities; + + +, severe abnormalities Reprinted from McCullough AJ. Malnutrition in liver disease. Liver Transplant 2000;6(4 Suppl 1):S85-S96.
Finally, patients with acute hepatitis had acute, rapid loss of nutrient stores. Similar findings were found more recently by Zaina et al. : 219 liver transplant candidates were classified as having cholestatic disease (n = 21) or noncholestatic disease (n = 198). Those with cholestatic disease tended to have calorie malnutrition and those with noncholestatic disease were more affected by malnutrition associated with protein depletion.
The degree of malnutrition in patients with liver disease also varies depending on the stage of liver disease. In a study by Figueiredo et al. , nutritional status was evaluated according to Child's score (a measure of the severity of liver disease). Those with Child's A classification (lowest severity) exhibited mainly fat loss. Patients classified with Child's B disease tended to have losses in at least one of two body compartments. Finally, those classified with Child's C disease (highest severity) tended to have depletion of both fat and muscle compartments. This conflicted with an earlier study by the same author in which there was no relationship between Child's score and BCM , as well as a study by Müller et al.  in which there were no significant differences in BCM and body fat based on Child's score. The findings that malnutrition was related to severity of liver disease were, however, confirmed in other studies by Rongpisuthiopong , Campillo  and Alberino .
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WHAT IT IS A three-phase plan that has been likened to the low-carbohydrate Atkins program because during the first two weeks, South Beach eliminates most carbs, including bread, pasta, potatoes, fruit and most dairy products. In PHASE 2, healthy carbs, including most fruits, whole grains and dairy products are gradually reintroduced, but processed carbs such as bagels, cookies, cornflakes, regular pasta and rice cakes remain on the list of foods to avoid or eat rarely.