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The new indirect calorimeter developed in the framework of the ICALIC project was first evaluated in ventilation mode. This second phase aimed to compare its ease of use and precision with another commonly used device in spontaneously breathing adult patients using a canopy hood or a face mask.The time required to measure resting energy expenditure (REE) with Q-NRG® in canopy and face mask mode was compared with Quark RMR® in canopy mode by sequential measurements in 45 and 40 spontaneously breathing adult patients, respectively. Their precision was assessed at different time intervals, using coefficients of variation (CV%) and repeated measures one-way ANOVA. Agreement between the two devices was evaluated by correlation coefficients, Bland-Altman plots, and paired t-test. Patients' characteristics potentially affecting the measurement were assessed using linear regression analysis.REE measurement with Q-NRG® was faster than Quark RMR® (19.7 ± 2.9 min vs 24.5 ± 4.3 min, P 0.001). In canopy mode, Q-NRG® gave values similar to Quark RMR®, with 73% of patients achieving a steady state (CV%10%) within the 5-15 min interval. In face mask mode, Q-NRG® was less stable than Quark RMR® in canopy mode, and steady state was achieved in only 40% of the patients within the 5-15 min interval. Correlation between the two devices was stronger when Q-NRG® was used in canopy than in face mask mode, with Pearson coefficients of 0.96 and 0.86, respectively. Compared to Quark RMR® in canopy mode, systematic bias±1.96∗SD with Q-NRG® was -14 ± 236 kcal/day in canopy and 73 ± 484 kcal/day in face mask mode. Q-NRG® in face mask mode overestimated REE by 150 ± 51 kcal/day in men compared to Quark RMR® in canopy mode.Q-NRG® in canopy mode made it possible to save at least 5 min compared to Quark RMR® while maintaining the same measurement precision. However, its use in face mask mode could lead to REE overestimation in men and, therefore, should not be recommended in the clinical setting.ClinicalTrials.gov no. NCT03947294.

Ten years ago, European health care professional societies, health associations and members of the European Parliament convened in Brussels to discuss the necessary and urgent actions needed to improve access, initiation and follow up nutritional care for European citizens. As a response to this, in 2014 the Optimal Nutritional Care for All (ONCA) campaign was launched under the leadership of the European Nutritional for Health Alliance and its members. As of today this campaign has been rolled out in 18 European countries, whereby national multi-disciplinary platforms including patient groups work together to implement national nutritional care programs and develop good practices in care, research, education in order to increase awareness on malnutrition and improve nutritional care. This article describes the making of and evolution of the ONCA campaign, the outcomes and impact created, as well as opportunities to accelerate implementation of personalized nutritional care for all European citizens.

Individualized supplemental parenteral nutrition (SPN) providing measured energy expenditure from day 4 reduced infectious complications in a previous study including 305 intensive care (ICU) patients. The study aimed at investigating the metabolic, and immune responses underlying the clinical response of the previous trial.Randomized controlled trial enrolling 23 critically ill patients on day 3 (D3) of admission to the ICU who were fed less than 60% of their energy target by the enteral nutrition (EN) alone: allocation to either continued EN or to SPN to a target validated by indirect calorimetry. Protein and glucose metabolism (primary endpoint) were investigated with tracer isotopes on D4 and D9. Secondary endpoints: 1) immune response, investigated in serum and in stimulated peripheral blood mononuclear cells (PMBC), by dosing a panel of cytokines (infectious complications were recorded), and 2) Muscle mass was assessed by ultrasound of the thigh.Comparable at baseline, the SPN group (n = 11) received more energy (median 24.3 versus 17.8 kcal/kg/day: p 0.001) and proteins (1.11 versus 0.69 g/kg/day: p 0.001) than the control group during the five days' intervention, resulting in a less negative energy balance by D9 (p = 0.0027). Net protein breakdown and Glucose kinetics on D9 did not differ, within or between groups. In agreement with a decrease in infection rate, immune response in the SPN group showed decreased serum IL-6 (p = 0.024), IL-1β, IL-10 levels and TNF-α secretion by PBMC (p = 0.018) at D9. Muscle mass loss from D4 to D15 tended to be less in the SPN group (-16% versus -23%: p = 0.06). Clinical course by D28 did not differ.Feeding patients to cover an individualised measured energy target with SPN from D4 to cover needs, was associated with improved immunity, less systemic inflammation and a trend to less muscle mass loss.NCT02022813 at https://clinicaltrials.gov/.

Summary Background & aims The severity of pain is routinely assessed in hospitalised patients but the impact of pain and pain control on energy coverage has been poorly studied. This One-day cross-sectional observational study assessed the association between severity of pain and coverage of energy needs in hospitalised patients. Methods Foods provided and consumed were assessed on one day by dedicated dieticians for unselected hospitalised patients receiving three meals per day. Severity of pain was evaluated by a visual analogue scale at the mealtimes, averaged over the study day, and categorized as no pain, slight, moderate or severe pain. The coverage of energy needs was expressed in percentage of predicted needs. Results Among the 755 included patients, 63% reported having pain. Severe pain was associated with a lower energy coverage than no pain (p = 0.001) or slight pain (p = 0.001). Insufficient energy coverage, defined as ≤70% of predicted needs, occurred in 13% of the patients. In univariate logistic regressions, predictors of insufficient energy coverage were severe pain as compared to no pain (OR 2.38; 95% CI 1.21, 4.64) and treatment with opioid drugs as compared to no pain killer (OR 1.73; 95% CI 1.07, 2.79). When including sex, age, body mass index, treatment with analgesics and severity of pain in a multivariate logistic regression, severe pain more than doubled the risk of insufficient energy coverage (OR 2.32; CI 1.15, 4.66). Conclusions Patients experiencing severe pain have a high risk of insufficient energy coverage. Optimal pain control is probably critical to prevent underfeeding in the hospital. Trial registration Identifier no NCT02463565 on www.ClinicalTrials.gov .

Background & aims This study determined the association between phase angle (PhA), by bioelectrical impedance analysis (BIA) and nutritional risk by Nutritional Risk Screening (NRS-2002), Subjective Global Assessment (SGA), hospital length of stay (LOS) and 30 day non-survival in patients at hospital admission compared to healthy controls. Methods PhA was determined by BIA in patients (n = 983, 52.7 ± 21.5 yrs, M 520) and compared to healthy age-, sex- and height-matched controls. Low PhA was set at

Body composition reflects nutritional intakes, losses and needs over time. Undernutrition, i.e. fat-free mass (FFM) loss, is associated with decreased survival, worse clinical outcome and quality of life, as well as increased therapy toxicity in cancer patients. In numerous clinical situations, such as sarcopenic obesity and chronic diseases, the measurement of body composition with available methods, such as dual-X ray absorptiometry, computerized tomography and bioelectrical impedance analysis, quantifies the loss of FFM, whereas body weight loss and body mass index only inconstantly reflect FFM loss. The measurement of body composition allows documenting the efficiency of nutrition support, tailoring the choice of disease-specific and nutritional therapies and evaluating their efficacy and putative toxicity. Easy-to-use body composition methods integrated to the routine of care allow sequential measurements for an initial nutritional assessment and objective patients follow-up. By allowing an earlier and objective management of undernutrition, body composition assessment could contribute to reduce undernutrition-induced morbidity, worsening of quality of life, and global health care costs by a timely nutrition intervention.

Amyotrophic lateral sclerosis (ALS) alters nutritional state, energy intake and energy expenditure. This article aims at reviewing present knowledge on these topics in order to determine energy requirements for maintaining a neutral energy balance in ALS patients. Maintaining a neutral energy balance prevents malnutrition and its complications and may improve physical functioning, quality of life and survival. Prevalence of malnutrition varies between 16 and 55% in ALS patients. Energy intakes are below recommended dietary allowances in 70% of ALS patients at least. These elements suggest a chronic negative energy balance with an imbalance between requirements and intakes. While insufficient intakes can be compensated with nutritional support, the energy requirements are unclear. Studies generally report hypermetabolism in ALS patients. Estimation of total energy expenditure and as a corollary energy needs, necessitates taking into account this hypermetabolism, physical activity and possibly mechanical ventilation. The review suggests a flow chart for optimal nutritional follow-up in clinics. Further studies are required to assess whether optimal nutritional follow-up improves outcome.

A food quality control and improvement permanent process was initiated in 1999. To evaluate the food service evolution, protein-energy needs coverage were compared in 1999 and 2008 with the same structure survey in all hospitalized patients receiving 3 meals/day.Nutritional values of food provided, consumed and wasted over 24h including non-exclusive nutritional support were calculated individually. Nutritional needs were estimated as 110% of Harris-Benedict formula for energy and 1.2 or 1.0 g protein/kg/day for patients65 or ≥65 years old, respectively. Multivariate analysis identified factors associated with low nutritional intake in both populations standardized to body mass index (BMI) of 1999's patients.Out of 1677 patients, 1291 were included. Mean BMI was higher in 2008 than 1999 (P0.001). The proportion of underfed patients was unchanged (69 vs. 70%, NS). The consumption of ≥1 oral nutritional supplements (ONS) daily increased the protein needs coverage from 80% to 115% (P0.001). The year 1999, high BMI, 1st week of hospital stay, specific diet, ONS absence and low meal quality were associated with low nutritional intakes.The nutritional needs coverage could have improved in 2008 if BMI was similar to 1999's. ONS consumption is associated with a lower risk of underfeeding in hospitalized patients.

BACKGROUND & AIMS: Optimal implementation of parenteral nutrition (PN) is required to promote clinical outcome and costs control. This prospective quality control study examined if PN prescription was justified and PN administration was adequate to cover the nutritional needs of patients hospitalized in the Geneva University Hospital. METHODS: Two-hundred consecutive patients receiving PN were included from Medicine, Intensive Care or Surgery Units. PN prescription was considered justified if oral feeding or enteral nutrition were contraindicated or provided less than 40% of the energy target after 5 days. PN was considered adequate if it covered 90%-110% of the recommended need for energy (i.e., 110% of the Harris-Benedict formula) and proteins (i.e., 1.2 or 1.0 g protein/kg body weight/day for patients < or = or >65 years, respectively), and was supplemented with vitamins and trace elements. RESULTS: PN prescription was justified in all but 14 patients (7%). However, PN administration was frequently inadequate: overfeeding (62%) was more often observed than underfeeding (14%), particularly among thin, elderly and female patients (P

Summary Background & aims Undernutrition in home care and care home settings is an unrecognized problem with significant consequences. The present work was edited after a forum concerning nutrition in these settings was held in Brussels in order to tackle the problem. Methods Various aspects of the question were addressed with the participation of scientific experts. The proceedings of the forum were edited and completed by a review of previously published material. Results Prevalence of undernutrition in home care and care home settings varies between 15% and 65%. Causes of undernutrition are various: medical, social, environmental, organizational and financial. Lack of alertness of individuals, their relatives and health-care professionals play an important role. Undernutrition enhances the risk of infection, hospitalization, mortality and alter the quality of life. Moreover, undernutrition related-disease is an economic burden in most countries. Nutritional assessment should be part of routine global management. Nutritional support combined with physical training and an improved ambiance during meals is mandatory. Awareness, information and collaboration with all the stakeholders should facilitate implementation of nutritional strategies. Conclusions Undernutrition in home care and care home settings is a considerable problem and measures should be taken to prevent and treat it.

BACKGROUND & AIMS: Acceptability and intake of oral nutritional supplements are often suboptimal, partly because patients dislike flavour, texture or smell. We assessed the taste preferences about milk-based and fruit-juice typed supplements in malnourished in-patients. METHODS: One hundred and nine in-patients requiring oral nutritional support were assigned to consume four given supplements on four consecutive days, to answer a questionnaire based on a 10-point visual analogue scale (VAS) on acceptance/tolerance, and to choose their preferred product for the fifth day. RESULTS: Overall pleasantness was significantly better for milk-based supplements than for sweet and salty fruit-juice typed products (on VAS: 6.2+/-3.1 versus 4.4+/-3.9, p

Summary Introduction There is a lack of validation studies of formulas for estimating resting metabolic rate (RMR) in healthy subjects over 70 years of age. Indirect calorimetry allows measuring RMR (RMRm), but is time consuming and costly and therefore formula are generally used to estimate RMR (RMRe). We assessed the degree of agreement between RMRm and RMRe predicted by five popular equations: Harris–Benedict (HB), Mifflin–St Jeor (MJ), Owen (OW), World Health Organization (WHO/FAO/UNU) and Luhrmann (LM) in a cohort of elderly subjects. Methods In 119 healthy subjects, aged 70–98yr, RMRm was obtained by indirect calorimetry and RMRe by the HB, MJ, OW, WHO/FAO/UNU and LM equations. Means were compared by paired t -test. The Bland and Altman method was used to assess agreement between RMRm and RMRe. Accuracy was defined as the % of individuals whose RMRe was within ±10% of RMRm. Results The HB showed the lowest mean RMRe-RMRm difference (−40.9kcal/day), followed by LM (+44.8kcal/day) and WHO/FAO/UNU (+53kcal/day). The HB performed the best of the five equations, having 72.4% of the cases within±10% of RMRm. In 18.7% of male subjects and 20% of female subjects HB underestimated the measured values. Conclusions Large discrepancies exist between RMRm and RMRe in subjects above 70 years of age. HB performs best, but still tends to underestimate in both sexes. In order to develop more accurate equations to estimate RMR in elderly subjects it would be worthwhile to examine whether additionally specific markers of body composition should be taken into consideration.

This review focuses on the studies investigating the prognostic implications of disease-related malnutrition. Malnutrition is a common problem in patients with chronic or severe diseases. Prevalence of hospital malnutrition ranges between 20% and 50% depending on the criteria used in order to determine malnutrition and the patient's characteristics. Furthermore, nutritional status is known to worsen during hospital stay which is partly due to the poor recognition by the medical staff and adverse clinical routines. Studies have repeatedly shown that clinical malnutrition however has serious implications for recovery from disease, trauma and surgery and is generally associated with increased morbidity and mortality both in acute and chronic diseases. Length of hospital stay is significantly longer in malnourished patients and higher treatment costs are reported in malnutrition. Since it has been demonstrated that proper nutritional care can reduce the prevalence of hospital malnutrition and costs, nutritional assessment is mandatory in order to recognise malnutrition early and initiate timely nutritional therapy.

Enteral nutrition (EN) is the preferred method of nutrition support in hospitalized patients but only 50-90% of the required calories are actually delivered. In order to identify where our nutrition support team (NST) should focus its activity, we prospectively evaluated the level of coverage of energy and protein needs during the first 5 days of EN in intensive care unit (ICU) and non-ICU patients and the relationship of energy and protein coverage with serum albumin, transthryretin, insulin-like growth factor-1 (IGF-1) and C-reactive protein (CRP).Subjects (n=183) who required nutrition support and received EN were prospectively recruited. Calorie prescription was 20 and 25, 25 and 30 kcal/kg BW for women and men 60 years and60 years, respectively. Protein needs were estimated as 1.2g protein/kg BW. Logistic regression analysis was used to estimate odds ratios (OR) for energy and protein delivery 66.6% and66.6% and albumin, transthryretin, IGF-1 (low vs. normal) and CRP (high vs. normal) in ventilated vs. non-ventilated patients.Significantly more mechanically ventilated than non-ventilated patients received66.6% of energy (71% vs. 48%) and protein (96% vs. 65%). The ventilated patients were more likely to be energy (OR 2.1, CI 1.1-4.0) and protein (OR 15.7, CI 4.9-50.8) underfed than non-ventilated patients. There was a significant association on day 5 between low protein delivery and low albumin (OR 2.9, CI 1.3-6.5), low transthyretin (OR 3.0, CI 1.4-6.5), low IGF-1 (OR 2.8, CI 1.2-6.7) and high CRP (OR 3.5, CI 1.6-7.8).The energy and protein needs of hospitalized patients are not met during the first 5 days of EN. Ventilated patients are more likely to be energy and protein underfed than non-ventilated patients and to have low plasma protein level. These findings support our decision to intensify EN monitoring by our NST in ventilated patients to optimize their nutritional coverage.

Summary Introduction This population study aimed to test the sensitivity and specificity of nutritional risk index (NRI), malnutrition universal screening tool (MUST) and nutritional risk screening tool 2002 (NRS-2002) compared to subjective global assessment (SGA) and to evaluate the association between nutritional risk determined by these screening tools and length of hospital stay (LOS). Methods Patients ( n =995) were assessed at hospital admission by four screening tools (SGA, NRI, MUST and NRS-2002). Sensitivity, specificity and predictive values were calculated to evaluate NRI, MUST and NRS-2002 compared to SGA. Multiple logistic regressions, adjusted for age, were used to estimate odds ratios (OR) and confidence interval (CI) for medium and high, compared to low risk in patients hospitalized >11, compared to 1–10 days LOS. Results The sensitivity was 62%, 61% and 43% and specificity was 93%, 76% and 89% with the NRS-2002, MUST and NRI, respectively. NRS-2002 had higher positive (85%) and negative predictive values (79%) than the MUST (65% and 76%) or NRI (76% and 66%, respectively). Patients who were severely malnourished or at high nutritional risk by SGA (OR 2.4, CI 1.5–3.9), MUST (OR 3.1, CI 2.1–4.7) and NRS-2002 (OR 2.9, CI 1.7–4.9) were significantly more likely to be hospitalized >11 days, compared to 1–10 days, than patients assessed as low risk. Conclusion NRS-2002 had higher sensitivity and specificity than the MUST and NRI, compared to SGA. There was a significant association between LOS and nutritional status and risk by SGA, NRS-2002, MUST and NRI. Nutritional status and risk can be assessed by SGA, NRS-2002 and MUST in patients at hospital admission.

Summary Background & aims Weight measured by dual-energy X-ray (DXA) was shown to be increasingly underestimated in subjects over 75 kg compared to an electronic scale. This study compares body weight and composition measured by balance beam scale and three DXA acquisition modes in obese subjects. Methods In 39 obese, body weight was measured by balance beam scale, and body weight and composition by DXA Hologic QDR4500A® in normal (NPM) and high power mode (HPM) (Enhanced v8.26 and v8.26* softwares) and DXA GE-Lunar Prodigy® (v6.5 software). To ensure linearity of body weight and composition measured by the different DXA acquisitions, we also measured 13 women with a body mass index (BMI) of 25–30 kg/m2. Results While QDR4500A HPM overestimates scale weight by about 2 kg over the whole BMI spectrum, QDR4500A NPM underestimates scale weight as a weight-dependent response (−1.7±1.8 kg overall, −4.1±1.6 kg in morbidly obese women). These results suggest switching from one mode to the other at a specific threshold, i.e. in our study a weight of 90 kg or a BMI of 34 kg/m2. Prodigy gives weight about similar to scale (+0.5±0.8 kg). Both Hologic acquisition modes underestimate fat mass but overestimate lean body mass compared to Prodigy. Conclusions The QDR4500A NPM is inappropriate in women over 90 kg. Unfortunately, the QDR4500A HPM overestimates body weight in the range of 90–150 kg. The difference between scale and Prodigy weight remains stable throughout weight ranges. To better assess their accuracies in terms of body composition, QDR4500A NPM, HPM and Prodigy should be tested against phantoms or in vivo multi-compartment models.

Regular physical activity prevents or limits weight gain, and gain in body mass index (BMI) and decreases mortality. The aims of the study in healthy adults were to determine the differences in fat-free mass index (FFMI) (kg/m(2)) and body fat mass index (BFMI) between age groups and determine the association between physical activity and FFMI and BFMI.Caucasian men (n=3549) and women (n=3184) between 18 and 98 years, were classified as either sedentary or physically active (at least 3h per week at moderate or high-intensity level activity). FFMI and BFMI were measured by 50 kHz bioelectrical impedance analysis.BFMI was significantly higher (P0.05) in sedentary than physically active subjects and the differences became progressively greater with age. The physically active subjects were significantly less likely to have a low or high FFMI (logistic regression, P0.001), and a high or very high BFMI (P0.001), and more likely to have low BFMI (P0.001) compared to sedentary adults. In contrast with fat-free mass, which was lower in older subjects, the height-normalized FFMI was stable with age until 74 years and lower thereafter. Significantly higher BFMIs were noted in older subjects.Physically active subjects are less likely to have low or high FFMI, and high or very high BFMI, and more likely to have low BFMI. In contrast to common claim that fat-free mass decreases with age, we found that FFMI was stable until 74 years. The use of FFMI and BFMI permits comparison of subjects with different heights and age.

Malnutrition, defined as low or excessive body weight, is associated with increased hospital length of stay and cost of care. The purpose of this study was to determine if fat-free mass (FFM) and body fat (BF) differed between patients at hospital admission in Geneva and Berlin and healthy volunteers, and if there is a difference in the prevalence of low FFM (percentile P10) and high BF (percentile P90) between patients and volunteers.In total, 1760 patients (Geneva: 525 men, 470 women; Berlin: 397 men, 368 women) were evaluated for malnutrition by BMI, serum albumin, and FFM and BF, determined by bioelectrical impedance analysis (BIA), and compared to 1760 healthy volunteers matched for age and height, and further compared to FFM and BF percentiles, previously determined in 5225 healthy adults.The prevalence of FFM P10 was greater in patients than controls. The prevalence of albumin35 g/l (14.9% and 11.2% in Geneva and Berlin patients, respectively) and BMI20.0 kg/m(2) was lower than the prevalence of low FFM (31.3% and 17.3%, respectively). The prevalence of high BF in Berlin patients was three-fold the prevalence of volunteers. Twelve and twenty percent of Geneva and Berlin patients, respectively, with normal BMI had high BF, compared to 4% of volunteers.Geneva and Berlin patients had lower FFM and higher BF than age-and height-matched volunteers and a higher prevalence of low FFM and high BF. Serum albumin and BMI underestimated the prevalence of malnutrition in patients at hospital admission. Body composition measurements identified patients with low FFM and low or high BF reserves.

The incidence of colon cancer in industrialised countries has increased since the early 1970s. It is estimated that more than one-third of cases are associated with factors related to a Western diet. Both the type and amount of dietary fats consumed have been implicated in colon cancer aetiology. Recent studies have demonstrated that n-3 polyunsaturated fatty acids (PUFAs), commonly found in fish oil (FO), could prevent colon cancer development. Evidences show that n-3 PUFAs act at different stages of cancer development and through several mechanisms including the modulation of arachidonic acid-derived prostaglandin synthesis, and Ras protein and protein kinase C expression and activity. As a result, n-3 PUFAs limit tumour cell proliferation, increase apoptotic potential along the crypt axis, promote cell differentiation and possibly limit angiogenesis. The modulatory actions of n-3 PUFAs on the immune system and their anti-inflammatory effects might also play a role in reducing colon carcinogenesis. There remains, nevertheless, some ambiguity over the safety of n-3 PUFAs with respect to secondary tumour formation. However, it appears that n-3 PUFAs may be of use in colon cancer prevention.

International audience; BACKGROUND AND AIMS: Radiation injury to the gut induces nutrient losses that compromise the body ability to adequately fight infection, heal wounds and recover from illness. Recombinant growth hormone (rhGH), is known to enhance anabolism, therefore, we tested the hypothesis that rhGH preserves whole body growth and trophism of the jejunum and ileum of irradiated rats. METHODS: After acclimatization period, the rats were divided in three groups: (1). control rats (C), (2). rats irradiated with a single dose of 10 Gy (group A); (3). rats irradiated with a single dose of 5 Gy (Group B); after irradiation, rats were given subcutaneously (sc) saline or 0.25 or 0.50 mg rhGH/kg BW/d for the following 6 days. Body weight changes were recorded during this time. On day 6 post-radiation, rats were killed and small intestine mucosa dry and wet weights were measured, as well as mucosa protein content. RESULTS: Group A rats lost body weight during the 6-day post-radiation period, regardless of rhGH treatment and dosage. rhGH was effective in preventing weight loss and normalizing growth in group B rats (saline 23.1+/-11.1, vs. controls P

The aim of the present study was to investigate the effects of continuous and acute L-carnitine supplementation of total parenteral nutrition (TPN) on protein and fat oxidation in severe catabolism. A critically ill and severely malnourished male patient received TPN (non protein energy = 41 kcal/kg/day, provided equally as fat and glucose) over 38 days, without L-carnitine for 23 days and with carnitine supplements (15 mg/kg/day) for the following 15 days. Subsequently, he was given carnitine-free enteral nutrition for 60 more days. A four-hour infusion of 100 mg L-carnitine was given on day 11 of each TPN period. Indirect calorimetry was carried out after 11 days of either carnitine-free or supplemented TPN and at the initiation of enteral nutrition. Additional measurements were performed 4 hours and 24 hours after the acute infusions of carnitine. The rate of protein oxidation and the respiratory quotient were found to be higher, and the rate of fat oxidation to be lower, with carnitine-supplemented TPN, than with either carnitine-free TPN or enteral nutrition. Acute infusion of carnitine resulted in an increased rate of protein oxidation and a reduced rate of fat oxidation on both TPN-regimens. These unfavourable effects on protein metabolism may be due to an impairment of fat oxidation by excess amounts of carnitine.