**2. Amyotrophic lateral sclerosis and nutritional status**

### **2.1 Food intake in ALS**

Few studies on food intake in patients with ALS are available in the literature. Among these studies, Kasarskis et al. (1996) studies stand out, which found that 70% of the subjects

Nutritional Care in Amyotrophic Lateral Sclerosis:

**2.2 Anthropometry and body composition** 

Stanich et al., 2004; Kasarskis et al., 1996; Slowie et al., 1983).

the age into account.

**2.2.1 Weight (W)** 

**2.2.2 Height (H)** 

**2.2.3 Body mass index (BMI)** 


The BMI classification is described below: - BMI < 16 kg/m2: severe malnutrition - 16 - 16.9 kg/m2: moderate malnutrition - 17.0 - 18.49 kg/m2: mild malnutrition

mass kg/height m²).

An Alternative for the Maximization of the Nutritional State 597

The activity factor is considered as 1.2 for patients unable to walk and 1.3 for patients able to walk. The injury factor is considered as 1.1 for chronic diseases (Long; Schaffel; Geiger, 1979). Considering a higher energy expenditure (10-20%) for individuals with ALS (Piquet,

For water intake, the estimation according to Thomas (2001) should be 30-35mL/kg, taking

The nutritional status can be evaluated through objective methods, such as: anthropometry, body composition, biochemical parameters and dietary consumption; or subjective methods, such as: physical examination and subjective global assessment. Anthropometry involves obtaining measures of body size, their proportions and the relationship with standards that reflect the development of adult subjects. The most used measures are weight, height, circumferences and skinfolds (Almeida et al., 2010; Silva et al., 2008b; Silva et al., 2008c;

For patients unable to walk, in the absence of a metabolic scale, the weight is measured using a wheelchair. Prior to patient's weighing, the wheelchairs are weighted and their weight is deducted at the time of calibration of the scale. In patients able to walk, the body weight is measured standing on platform type or digital scales (Silva et al., 2008b; Stanich et

The height for individuals unable to walk is measured with the subject seated closest to the edge of the chair with his/her left knee bent at 90 degrees. The length between the plantar surface and the knee is measured with the help of a measuring tape. The height is estimated

> Men's height = 64.19 - 0.04 x age in years + 2.02 x knee height in cm Women's height = [84.88 - 0.24 x age in years + 1.83 x knee height in cm

Usually, body mass-height ratio is used as an indicator of body mass index (BMI = body

 

al., 2004). The weight can also be measured in chair scales, available in the market.

according to the equations proposed by Chumlea; Roche; Steinbaugh (1985), where:


2006), some professionals also employ 35 kcal/kg current body weight.

experienced energy intake below the RDA and 84% of the patients experienced protein intake above the RDA. Slowie et al. (1983) found, as well as Kasarskis et al. (1996), 70% of inadequacy for energy, using the 24-hour recall in patients with ALS. Stanich et al. (2004), found values above the RDA for lipids in most ALS patients chosen in their study.

Silva et al. (2007a and 2007b) analyzed the nutritional profile of patients treated in Dysphagia and Neuromuscular Outpatient Clinics of the Hospital das Clínicas of Unicamp – HC/UNICAMP. Interdisciplinary assessments were performed, revealing a low caloric intake of approximately 1600 kcal for men. In women, a low caloric intake (approximately 1700 kcal/day) was also observed.

In another study conducted by Silva et al. (2008a) the food intake was quantitatively and qualitatively assessed in ALS patients regularly followed at the neuromuscular outpatient clinic of the HC-UNICAMP. The foods most consumed daily were oil, rice, beans, French bread and milk. The food was found to be inadequate regarding energy, fiber, calcium and vitamin E. A significant difference was observed between patients with ALS of bulbar and appendicular predominance, whereas, in patients with higher appendicular manifestation, a higher energy intake (p=0.02) of saturated fat (p=0.03), monounsaturated fat (p=0.04) and polyunsaturated fat (p=0.001), as well as cholesterol (p=0.001) and fibers (p=0.001) was observed when compared with the ALS of bulbar predominance. A higher swallowing impairment observed in patients with bulbar predominance may have influenced the qualitative and quantitative intake. While feeding is impacted by the disease features, the per capita income of patients seems to have influenced the low qualitative consumption of food. Based on the results obtained, the authors suggested that guidance regarding the consumption of foods and preparations with a higher content of high-biological proteins, fibers, calcium, and vitamin E is necessary.

In ALS, as in most neuromuscular diseases, changes can also be observed, which increase the muscle catabolism, directly impacting protein synthesis and mineral excretion. In the initial stages of the disease, according to the study conducted in 94 patients with ALS, it was observed no deficiency of vitamins E and C, but upon disease progression, clinical and biochemical manifestations of such deficiency were observed (Ludolph, 2006).

To estimate the dietary intake, some countries in Europe and Canada use as main practices the 24-hour recall, 3-day and 7-day food record. To estimate the energy requirements, professionals have used the equations of Schofield (1985) and Harris and Benedict (1919). To estimate the adequacy of macronutrients, the researchers used the standards of the Recommended Dietary Allowances (NCR, 1989), Department of Health (1991) and the Institute of Medicine (IOM, 2002; IOM, 2001; IOM 2000; IOM 1997).

To estimate the energy requirements, the most used equation was that of Harris and Benedict (1919) modified by Long; Schaffel; Geiger (1979).

According to Harris and Benedict:

 Men: BMR\* = 66 + 13.7 x mass in kg + 5 x height in cm – 6.8 x age in years Women: BMR\* = 655 + 9.6 x mass in kg + 1.7 x height in cm – 4.7 x age in years

\*BMR = basal metabolic rate

Modified by Long; Schaffel; Geiger (1979): VET\* = BMR x activity factor x injury factor \*TEV = total energy value

The activity factor is considered as 1.2 for patients unable to walk and 1.3 for patients able to walk. The injury factor is considered as 1.1 for chronic diseases (Long; Schaffel; Geiger, 1979). Considering a higher energy expenditure (10-20%) for individuals with ALS (Piquet, 2006), some professionals also employ 35 kcal/kg current body weight.

For water intake, the estimation according to Thomas (2001) should be 30-35mL/kg, taking the age into account.
