title: Assessing protein energy wasting in a Malaysian haemodialysis population using self-reported appetite rating: a cross-sectional study.
abstract: BACKGROUND
  Poor appetite could be indicative of protein energy wasting (PEW) and experts recommend assessing appetite in dialysis patients. Our study aims to determine the relationship between PEW and appetite in haemodialysis (HD) patients.
  
  
  METHODS
  HD patients (n=205) self-rated their appetite on a scale of 1 to 5 as very good (1), good (2), fair (3), poor (4) or very poor (5). Nutritional markers were compared against appetite ratings. Using logistic regression analysis associations between dichotomized appetite with PEW diagnosis were determined as per the International Society of Renal Nutrition and Metabolism (ISRNM) criteria and alternate objective measures. Data was adjusted for socioeconomic and demographic characteristics.
  
  
  RESULTS
  Poorer appetite ratings were significantly associated with lower income (P = 0.021), lower measurements (P < 0.05) for mid-arm muscle circumference, mid-arm muscle area and lean tissue mass (LTM), serum urea (P = 0.007) and creatinine (P = 0.005). The highest hsCRP (P = 0.016) levels occurred in patients reporting the poorest appetite. Serum albumin did not differ significantly across appetite ratings. Poor oral intake represented by underreporting (EI/BMR < 1.2) was evident for all appetite ratings. PEW was prevalent irrespective of appetite ratings (very good: 17.6 %, good: 40.2 %, fair: 42.3 % and poor: 83.3 %). After dichotomizing appetite ratings into normal and diminished categories, there was a marginal positive association between diminished appetite and overall PEW diagnosis (OR adj: 1.71; 95 % CI: 0.94-3.10, P = 0.079). Amongst individual ISRNM criteria, only BMI < 23 kg/m2 was positively associated with diminished appetite (OR adj: 2.17; 95 % CI: 1.18-3.99). However, patients reporting diminished appetite were more likely to have lower LTM (OR adj: 2.86; 95 % CI: 1.31-6.24) and fat mass (OR adj: 1.91; 95 % CI: 1.03-3.53), lower levels of serum urea (OR adj: 2.74; 95 % CI: 1.49-5.06) and creatinine (OR adj: 1.99; 95 % CI: 1.01-3.92), higher Dialysis Malnutrition Score (OR adj: 2.75; 95 % CI: 1.50-5.03), Malnutrition Inflammation Score (OR adj: 2.15; 95 % CI: 1.17-3.94), and poorer physical (OR adj: 3.49; 95 % CI: 1.89-6.47) and mental (OR adj: 5.75; 95 % CI: 3.02-10.95) scores.
  
  
  CONCLUSIONS
  A graded but non-significant increase in the proportion of PEW patients occurred as appetite became poorer. However, after dichotomization, a positive but marginally significant association was observed between diminished appetite and PEW diagnosis.
authors.affiliation: Dietetics Program, School of Healthcare Sciences, Faculty of Health Sciences, National University of Malaysia, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia. sham_0901@yahoo.com.
authors.forename: Sharmela
authors.initials: S
authors.lastname: Sahathevan
authors.affiliation: Dietetics Program, School of Healthcare Sciences, Faculty of Health Sciences, National University of Malaysia, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia. jeremysch3232@gmail.com.
authors.forename: Chee Hee
authors.initials: CH
authors.lastname: Se
authors.affiliation: Dietetics Program, School of Healthcare Sciences, Faculty of Health Sciences, National University of Malaysia, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia. seehoe88@gmail.com.
authors.forename: See Hoe
authors.initials: SH
authors.lastname: Ng
authors.affiliation: Epidemiology and Biostatistics Unit, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia. karuthan@gmail.com.
authors.forename: Karuthan
authors.initials: K
authors.lastname: Chinna
authors.affiliation: Division of Nutrition and Dietetics, School of Health Sciences, International Medical University, No.126, Jalan Jalil Perkasa 19, Bukit Jalil, 57000, Kuala Lumpur, Malaysia. harvin3386@yahoo.com.
authors.forename: Gilcharan Singh
authors.initials: GS
authors.lastname: Harvinder
authors.affiliation: Division of Nutrition and Dietetics, School of Health Sciences, International Medical University, No.126, Jalan Jalil Perkasa 19, Bukit Jalil, 57000, Kuala Lumpur, Malaysia. winnie_chee@imu.edu.my.
authors.forename: Winnie Siew Swee
authors.initials: WS
authors.lastname: Chee
authors.affiliation: Department of Nephrology, Serdang Hospital, Jalan Puchong, 43000, Kajang, Selangor, Malaysia. bak.leong@gmail.com.
authors.forename: Bak Leong
authors.initials: BL
authors.lastname: Goh
authors.affiliation: Nephrology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur, 56000, Malaysia. halimgafor@gmail.com.
authors.forename: Halim A
authors.initials: HA
authors.lastname: Gafor
authors.affiliation: Department of Nephrology, Kuala Lumpur Hospital, Jalan Pahang, 50586, Kuala Lumpur, Malaysia. sbavanandan@gmail.com.
authors.forename: Sunita
authors.initials: S
authors.lastname: Bavanandan
authors.affiliation: Department of Nephrology, Kuala Lumpur Hospital, Jalan Pahang, 50586, Kuala Lumpur, Malaysia. ghazaliahmad@moh.gov.my.
authors.forename: Ghazali
authors.initials: G
authors.lastname: Ahmad
authors.affiliation: Dietetics Program, School of Healthcare Sciences, Faculty of Health Sciences, National University of Malaysia, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia. tilly_karu@yahoo.co.uk.
authors.forename: Tilakavati
authors.initials: T
authors.lastname: Karupaiah
mesh_terms: D000328:Adult; D000368:Aged; D000855:Anorexia / Q000175:diagnosis* / Q000453:epidemiology / Q000378:metabolism; D001066:Appetite; D001132:Arm; D002097:C-Reactive Protein; D003430:Cross-Sectional Studies; D004044:Dietary Proteins; D005260:Female; D018737:Hand Strength; D006801:Humans; D007182:Income; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000378:metabolism / Q000628:therapy*; D008296:Malaysia / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D018482:Muscle, Skeletal; D009929:Organ Size; D011502:Protein-Energy Malnutrition / Q000175:diagnosis* / Q000453:epidemiology / Q000378:metabolism; D006435:Renal Dialysis; D057566:Self Report; D012709:Serum Albumin / Q000378:metabolism; D013851:Thinness / Q000175:diagnosis* / Q000453:epidemiology / Q000378:metabolism; D019282:Wasting Syndrome / Q000175:diagnosis* / Q000453:epidemiology / Q000378:metabolism
chemical_list: D004044:Dietary Proteins; D012709:Serum Albumin; D002097:C-Reactive Protein