CLINICAL RESEARCH STUDY

Serum Albumin and Prealbumin in Calorically

Restricted, Nondiseased Individuals:
A Systematic Review
Jessica L. Lee, MD, MS, Esther S. Oh, MD, Rebecca W. Lee, MD, Thomas E. Finucane, MD
Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, Md.

ABSTRACT

PURPOSE: Undernutrition is often suspected in patients when serum albumin or prealbumin levels are low.
We asked whether these measures are indeed low in undernourished people if no inflammatory illness is
present.
METHODS: We did a systematic review to identify otherwise healthy subjects who were severely nutrient-
deprived due to poor access to food or unwillingness to eat. We excluded children and pregnant women.
We tabulated available measures of nutrient intake, anthropometry, serum albumin and prealbumin, and,
when available, changes in these measures during nutritional intervention.
RESULTS: In otherwise healthy subjects, serum albumin and prealbumin levels remained normal despite
marked nutrient deprivation until the extremes of starvation, that is, body mass index <12 or more than 6
weeks of starvation.
CONCLUSIONS: In these otherwise healthy subjects, serum albumin and prealbumin levels are not “markers
of nutritional status.” The “markers” failed to identify subjects with severe protein-calorie malnutrition until
extreme starvation. That is, they failed to identify healthy individuals who would benefit from nutrition
support, becoming abnormal only when starvation was already obvious. In contrast, serum albumin and
prealbumin levels are known to fall promptly with injury or illness regardless of nutrient intake. They are
negative acute-phase reactants. When these measures are low in sick patients, this cannot be assumed to
reflect nutritional deprivation. Decisions about nutrition support should be based on evidence of meaningful
benefit from this treatment rather than on assessment of “nutritional markers.”
Ó 2015 Elsevier Inc. All rights reserved.
The American Journal of Medicine (2015) 128, 1023.e1-1023.e22

KEYWORDS: Albumin; Malnutrition; Nutrition; Nutrition screening; Prealbumin

Malnutrition is considered a common, serious problem
among ill patients. Serum albumin and prealbumin often
are used to identify malnutrition and evaluate the success
of nutrition support. For example, federal regulations for
care in nursing homes explicitly require that “The facility
Funding: JLL received funding support from a T32AG000120-25
fellowship training grant (National Institutes of Health/National Institute
on Aging).
Conflict of Interest: None.
Authorship: All authors had access to the data and a role in writing this
manuscript.
Requests for reprints should be addressed to Thomas E. Finucane, MD,
Department of Medicine, Division of Geriatric Medicine and Gerontology,
Mason F. Lord Building, Center Tower, 5200 Eastern Avenue, Suite 2200,
Baltimore, MD 21224.
E-mail address: tfinucan@jhmi.edu
must ensure that a resident: 1) maintains acceptable pa-
rameters of nutritional status, such as body weight and
protein levels, unless the resident’s clinical condition
demonstrates that this is not possible; and 2) receives a
therapeutic diet when there is a nutritional problem.”1 The
Centers for Medicare and Medicaid Services also put forth
a guide for long-term care surveyors evaluating nutrition
and sanitary conditions, which states that “albumin and
pre-albumin may help in some cases in deciding to initiate
nutritional interventions .”2 These regulations and this
guide are very influential during nursing home surveys,
and as a result they are influential in the nutritional
treatments provided by nursing homes. A 2014 article
recommends use of albumin and prealbumin levels to
identify malnutrition before orthopedic surgery and to
guide preoperative nutritional management, noting that

0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjmed.2015.03.032
1023.e2 The American Journal of Medicine, Vol 128, No 9, September 2015

normalization of levels should reduce perioperative com- complete list of the search strategy for each database can
plications.3 Another finds serum albumin level to be the be found in Appendix 1, available online. The results of
optimal guide for predicting malnutrition in heart trans- the searches were then transferred into the RefWorks
plant patients.4 A third notes that “Amongst the nutritional (2013; ProQuest LLC, Ann Arbor, MI) online database.
biomarkers used, serum albumin has been, by far, the most Duplicates were removed using the RefWorks exact du-
extensively studied serum protein in patients on mainte- plicates and close duplicates function. Two authors (JLL
nance dialysis.”5 and RWL) then independently
Serum albumin and pre- reviewed the remaining studies
albumin also are affected by in- CLINICAL SIGNIFICANCE for exclusion/inclusion criteria.
flammatory illness, however, and
Serum levels of albumin and prealbumin
their value in diagnosing malnu- continue to be used as “markers of
trition in sick patients has long
Study Selection
nutritional status.” Studies were considered, regard-
been questioned; “When there is
evidence of an acute-phase
They remain normal during starvation, less of study design, if they
response (eg, increased CRP [C- however, and are low in inflammatory included human subjects aged 13
years and older. We tabulated and
reactive protein]), decreased illness.
concentrations of plasma proteins graphed the results of studies of

Initiating nutrition support because participants who had both 1) evi-
such as albumin, transferrin,
retinol-binding protein and pre- these measures are low has no evidence dence of undernutrition, based on
albumin cannot be assumed to base and leads to significant waste. anthropometric measures, history
6
reflect malnutrition.” Low albu- of marked caloric restriction, or
min and prealbumin levels are both; and 2) measurements of
recognized particularly as “reverse acute phase reactants,” serum albumin, prealbumin, or both. We excluded studies
lowered during many inflammatory illnesses regardless of that involved children, pregnant women, hospitalized pa-
nutrient intake. 6-8 tients, or patients with known injury or acute or chronic
We asked whether starvation affects albumin and pre- inflammatory disease, such as malignancy, acute infection,
albumin levels in the absence of inflammatory illness. We specific organ failure, and surgery.
reviewed studies of healthy subjects with markedly
restricted caloric intake, usually due to poor access to food Data Abstraction
or because of unwillingness to eat for psychiatric, political, Detailed reasons for exclusion are documented in the flow
research, or other reasons. diagram (Figure 1). Articles that were categorized
We use “malnourished” to mean “undernourished” as is discordantly between the 2 reviewers or designated
common. We do not discuss albumin or prealbumin ki- “uncertain” had their full text reviewed and discussed. If
netics, acknowledging that serum levels are affected by disagreement remained, then a third reviewer (TEF) cast
synthesis, degradation, loss, and volume of distribution; the tie-breaking vote.
we simply present the measures used in clinical practice. All articles included in the final analysis underwent a
Children, pregnant women, and patients with known in- double data extraction process by the reviewers. We
flammatory illness are not considered here. extracted demographic information, anthropometric mea-
surements, information about caloric intake, and measures
of serum albumin/prealbumin. If multiple albumin mea-
METHODS surements were reported, we used the mean values
measured during caloric restriction. We also recorded the
Search Strategy change in albumin and prealbumin levels after any
We developed a written protocol before our review nutritional interventions. As is common in clinical prac-
following the standards listed in the Preferred Reporting tice, we used serum albumin levels <3.5 g/dL and pre-
Items for Systematic Reviews and Meta-Analyses albumin levels <20 mg/dL as the lower limits of
(PRISMA).9 normal.2,10-12
We searched PubMed, Embase, CINAHL, and Cochrane
Library databases for published studies from inception up to
the last search date of August 28, 2013. We did not use any RESULTS
restrictions on language, study type, or publication year. We A total of 63 articles were included in the final data
hand-searched the reference lists of included studies for extraction process, with the complete details listed in
other articles possibly relevant to our topic. We did not Appendix 2, available online.13-75 The studies were a mix
incorporate data from unpublished studies, conferences, of case reports, case control, cross-sectional, observational,
dissertations, or other grey literature. and cohort studies, and clinical trials, with dates ranging
We used a combination of keywords and headings from 1944 to 2012. A total of 2125 mostly female patients
related to albumin, prealbumin, and caloric restriction. A between the ages of 13 and 50 years were studied. Most of
Lee et al Serum Albumin and Prealbumin During Starvation
Figure 1 Albumin and prealbumin flow diagram.9
the reasons for nutrition restriction involved anorexia
nervosa, bulimia nervosa, or both. Other reasons for nutri-
tion restriction included dieting, lack of access to food,
prisoners, hunger strikers, and involvement in research
studies. The average duration of nutrition restriction ranged
from 4 days to 20 years.
The relationship between body mass index (BMI) and
mean serum albumin values is shown in Table 1 and
Figure 2. Of 33 studies with a total of 1695 patients,13-46
4 mean albumin values below 3.5 g/dL were recorded.
Three (3.35, 3.24, 2.95 g/dL) were recorded in groups of
patients with anorexia nervosa and average BMI values of
9.8, 11.1, and 10.5 kg/m2 respectively.14,24,35 The fourth was
1023.e3
3.4 g/dL in a group of prisoners on hunger strike for an
average 43 days with a mean BMI of 21.5 kg/m2.39 All other
mean albumin values were above 3.5 g/dL, in groups with
mean BMI as low as 11.3 kg/m2.
Table 2 and Figure 3 show the relationship between
BMI and mean serum prealbumin values in 20 studies with
a total of 1052 patients.13,14,17,21,23,25-29,33,35,38,39,42,43,46-49
Two mean prealbumin values were below 20 mg/dL
(13, 14.4 mg/dL), both among groups of patients with
anorexia nervosa and corresponding mean BMI of 9.8 and
11.1 kg/m2, respectively.14,35 All other mean prealbumin
values were above 20 mg/dL in groups with mean BMI
as low as 12.9 kg/m2.
 1023.e4
Table 1 Albumin and Body Mass Index (BMI)
# of Reason for Nutrition Duration of Nutrition
Study (First Author) Year Subjects Age (years) Sex Restriction Restriction BMI (kg/m2)  SD Albumin (g/dL)  SD
Nishida 13
2010 210 29.9  5.31 F BMI <18.5 but no 17.5  0.78 4.49  0.2
anorexia nervosa
118 32.9  4.29 F Self-reported wt loss >1 kg 20.7  3.33 4.45  0.21
Rigaud14 2000 5 29.8  9.3 F Near-death anorexia nervosa 9.77  0.1 3.35  0.28
16 25.2  3.9 Anorexia nervosa 13.6  1.1 4.05  0.58
Chui15 2008 63 21.3  2.3 F Anorexia nervosa 6.5  1.7 years 21.8  3.4 4.13  0.28
Dostalova16 2010 16 24.9  1.34 F Anorexia nervosa 15.7  0.3 4.38  0.112
Gendall17 1999 152 25.9  6.0 F Bulimia nervosa 71.1  65.6 months 23  2.7 4.87  0.34
Gentile18 2011 298 19.8  6.1 278 F, 20 M Anorexia nervosa, eating 14.6  2.1 4.8  0.5
disorder not otherwise
specified
Hildebrandt19 2001 28 Anorexia nervosa 5.0  4.2 years 13.7  2.3 4.86  0.73
24 bulimia nervosa 6.7  5.5 years 19.1  3.7 4.75  0.62
Mukamel20 2001 1 13.5 F Anorexia nervosa 10 months 11.25 4.7
Murciano21 1994 15 24.9  8.7 F Anorexia nervosa 12 months 13.5  1.1 3.99  0.21
Rodrigues Pereira22 2010 11 15.0  0.5 F Anorexia nervosa 15.1  0.6 4.7  0.1
Varela23 1991 17 15.68  0.95 F Anorexia nervosa 1.54  0.21 years 14.67  0.27 4.41  0.06

The American Journal of Medicine, Vol 128, No 9, September 2015

19 18.47  0.75 F Anorexia nervosa 3.80  0.54 years 17.93  0.25 4.2  0.08
Zastrow24 2011 1 26 F Anorexia nervosa 14 years 10.5 2.95
Agnello25 2012 39 26  9 F Anorexia nervosa 60 months 13.9  2 4.6  0.6
Caregaro26 2001 59 22.6  7.1 F Anorexia nervosa 14.87  1.89 4.582  0.578
23 27  7.2 F Bulimia nervosa 20.02  1.64 4.433  0.511
Chu27 2012 62 27 56 F, 6 M Anorexia nervosa 12.9  2 3.7  0.7
Haluzik28 1999 17 24.1  3.82 F Anorexia nervosa 15.22  3.06 4.903  0.602
Haluzik29 1999 11 23.7  3.1 F Anorexia nervosa 15.4  3.2 4.93  0.28
Herzog30 1997 66 20.8 F Anorexia nervosa 13.7 4.171  0.552
Krantz31 2005 1 52 F Anorexia nervosa 20 years 17 4
Lawson32 2009 10 27.5  2.4 F Anorexia nervosa 18.3  0.3 4.7  0.1
10 25.8  1.1 F Anorexia nervosa 18  0.4 4.4  0.1
Nova33 2004 14 15.1  2.56 F Anorexia nervosa 9.4  6.3 months 15.24  1.71 4.51  0.69
Olubodun34 1996 81 27.7  5.9 M Prisoners 229.1  210.1 days 20  2.7 3.66  0.63
Rigaud35 2009 16 26  9 (all) 115 F, 5 M (all) Anorexia nervosa 11.1  0.65 3.24  0.51
35 Anorexia nervosa 13.1  0.5 4.02  0.69
35 Anorexia nervosa 15  0.49 4.18  0.63
21 Anorexia nervosa 16.8  0.51 4.34  0.64
13 Anorexia nervosa 19.5  2.4 4.11  0.72
Rock36 1995 13 26  8 12 F, 1 M Anorexia nervosa, 6.4  3.3 years 17.4  2.9 4.1  0.5
Bulimia nervosa
Smith37 1996 6 27.2  2.36 F Anorexia nervosa 15.35  0.694 3.7  0.193
Van Binsbergen38 1988 20 24.7 F Anorexia nervosa 4.9 years 14.4 4.07
Lee et al Serum Albumin and Prealbumin During Starvation 1023.e5

0.000000402 g/dL)
Four studies of changes in mean serum albumin and
Albumin (g/dL)  SD

0.67  0.06 nmol/L

BMI before and after nutritional supplementation are re-

(0.00000489 
ported in Appendices 3 and 4, available online.16,29,33,39
4.863  0.264
3.4  0.3
In each, the BMI increased by about 2 kg/m2 during the

4.24
4.6

3.9
4.6
4.58079 nutritional supplementation. In 2, the mean albumin values
increased,16,33 while in the other 2 studies they
decreased.29,39 One mean albumin value began below
3.5 g/dL (3.4 g/dL) and decreased to 3.2 g/dL after sup-
BMI (kg/m2)  SD

plementation.39 Four studies measured the changes in

prealbumin and BMI before and after nutritional supple-
21.5  2.6
15.5  2.9

mentation and are reported in Appendices 5 and 6,

14.6  2
14.7
16.5
24.5

14.2

available online.29,33,46,48 All 4 showed an increase in

21

BMI after supplementation. Three studies showed an in-

crease29,46,48 and one study showed a decrease in mean
prealbumin values.33 There were no mean prealbumin
values <20 mg/dL, before or after nutritional
Duration of Nutrition

supplementation.
43 days

57 days

Four studies reported changes in mean albumin values

Restriction

and weight in 9 groups before and after nutrition restric-

tion (Appendices 7 and 8, available online).50-54 All
studies demonstrated weight loss. Six groups50,51
comprising 2 long-term (24 weeks and 46 days, respec-
tively) studies50 showed a decrease in mean albumin
values, while 3 short-term (less than a week) studies52-54
showed an increase. None of the mean albumin values
Reason for Nutrition

fell below 3.5 g/dL.

Anorexia nervosa
Anorexia nervosa
Anorexia nervosa

Anorexia nervosa
Anorexia nervosa
Bulimia nervosa
Hunger strikers

Hunger strikers

DISCUSSION
Restriction

In otherwise healthy patients who are chronically or acutely

undernourished, serum albumin and prealbumin levels have
no value as “markers of nutritional status” that can identify
undernutrition and the need for feeding. These serum mea-
sures remain normal until starvation is obvious by history
17 F, 3 M
1 F, 7 M

1 F, 7 M

(eg, prolonged fasting), physical examination (eg, BMI

Sex

F
F

F
F

below 12), or both.

The study has limitations. First, we have no data on
micronutrient deficiencies, a clear risk during long starva-
tion. These were rarely reported, and many of the included
subjects received vitamin supplementation. Second, in the
43.3  6.2

15.6  2.3
Age (years)

study by Keys et al,50 prolonged undernutrition led to falls

13.3

32.6
20
26

15

in albumin of up to 0.6 g/dL in a group of patients who lost

*Conversion to g/dL gave a nonphysiologic number.

an average of 18 kg (25% of initial body weight). Average

serum albumin levels remained above 3.5 g/dL. Changes
like this may be important but they do not now add to the
Subjects

clinician’s ability to identify patients in need of nutrition

# of

8
14
20
33
18
8
23
25

support.
In 1979, Seltzer et al76 declared that 2 readily available
“parameters, albumin (a measure of visceral protein) and
2001
1998
1991
2005
2004
2011
1993
2002
Year

total lymphocyte count (a poor man’s assessment of

Continued

immunocompetency) will form the basis of instant nutri-

Study (First Author)

tional assessment.” Low values were strongly associated

with mortality among hospitalized patients, and the au-
thors recommended that their assessment “be performed
39

*Pascal46
Haluzik40
Table 1

Dubois44
Faintuch

on all hospitalized patients with appropriate alterations

Roijen41
Cortes42

Okabe45
Orgaz43

and therapy being made to allow for nutritional repletion.”

This has been cited as the first description of nutritional
1023.e6 The American Journal of Medicine, Vol 128, No 9, September 2015
Figure 2 Albumin and body mass index.
assessment,77 and some clinicians and researchers
continue to use serum albumin (and prealbumin) in this
way. Acknowledging the effects of inflammatory illness
on these measures, however, the 2012 “Consensus State-
ment from the Academy of Nutrition and Dietetics and the
American Society for Parenteral and Enteral Nutrition:
Characteristics Recommended for the Identification and
Documentation of Adult Malnutrition (Undernutrition)”
no longer include these measures or any other biomarkers,
focusing instead on “insufficient energy intake,” and
anthropometric and functional measures.78
Recommended methods of nutritional assessment, such
as these, generally share 2 common characteristics. First, the
proposed assessments neither provide nor require any evi-
dence that nutrition support will benefit patients who are
identified as malnourished. Second, severe illness and injury
can independently affect every element of both proposals
regardless of nutrient intake (except “insufficient energy
intake”). There is no effort to account for the effects of
inflammation, which can closely mimic undernutrition.
Both serious illness and injury can cause reduced
appetite and nutrient intake (as part of “sickness
behavior”79), weight loss, sarcopenia, and weakness, as
well as prompt falls in serum albumin and prealbumin.6
Thus, sick or injured patients can be “malnourished,”
both by the Consensus Statement and the Seltzer assess-
ment, regardless of nutrient intake. Worsening the confu-
sion, if illness or injury improves and the inflammatory
state abates, appetite improves, nutrient intake increases,
and weight, strength, and blood biochemistry improve,
creating the appearance that better nutrient intake caused
the overall clinical improvement.
As conventionally used, then, the term “malnourished”
has 2 distinct meanings. First, the term can mean that a
patient’s “markers of nutritional status” are abnormal. The
term can also mean that there is evidence to suggest the
patient will benefit from nutrition support. The distinction
is critical. A patient with advanced cancer, for example,
will likely have very poor intake, weight loss, low serum
albumin, and moreeand be clearly malnourished in the
former sense. Yet “[i]n general, the data failed to
demonstrate the clinical efficacy of providing nutrition
support to most patients with cancer.”80 The patient is not
malnourished in the latter sense. We believe the term
should be used only in the latter sense, because a diag-
nosis of “malnutrition” will generally lead to treatment
with nutrition support.
Whether nutrition support will benefit patients with in-
flammatory illness remains a research question. Simply
adding energy, protein, and micronutrients to a patient with
an inflammatory, cachectic illness may not be beneficial.
Several reviews demonstrate little or no benefit in conditions
where malnutrition is classically considered to play a central
roleefor example, advanced dementia, wasting illness,
pressure ulcers, and cancer.80-84 Randomized controlled
trials are necessary to define the clinical situations where
supplements and enteral or parenteral feeding provide net
benefit to sick patients. These trials could generate mean-
ingful biomarkers that help find patients who will benefit
from nutrition support.
 Lee et al
Serum Albumin and Prealbumin During Starvation
Table 2 Prealbumin and Body Mass Index (BMI)
Study Reason for Nutrition Duration of Nutrition
(First Author) Year # of Subjects Age (years) Sex Restriction Restriction BMI (kg/m2)  SD Prealbumin (mg/dL)  SD
Nishida 13
2010 210 29.9  5.31 F Underweight 17.5  0.78 23.3  3.56
118 32.9  4.29 F Self-reported wt loss >1 kg 20.7  3.33 23.1  3.84
Rigaud14 2000 5 29.8  9.3 F Near-death anorexia nervosa 9.77  0.1 13  6
16 25.2  3.9 F Anorexia nervosa 13.6  1.1 31  6
Gendall17 1999 152 25.9  6.0 F Bulimia nervosa 71.1  65.6 months 23  2.7 27  5
Murciano21 1994 15 24.9  8.7 F Anorexia nervosa 12 months 13.5  1.1 24  4
Varela23 1991 17 15.68  0.95 F Anorexia nervosa 1.54  0.21 years 14.67  0.27 40  10
19 18.47  0.75 F Anorexia nervosa 3.80  0.54 years 17.93  0.25 50  10
Vogele47 2009 8 23.2  3.1 F Fasting bulimia nervosa 5.5  4.1 years (all) 22  3.1 24  5.1
9 24.5  8.5 F Nonfasting bulimia nervosa 23.3  3.3 30.1  6.3
Agnello25 2012 39 26  9 F Anorexia nervosa 60 months 13.9  2 26.3  7.4
Barbe48 1993 12 16-31 F Anorexia nervosa 6 months-4 years 13.8  0.5 25  2
Caregaro26 2001 59 22.6  7.1 F Anorexia nervosa 14.87  1.89 27.924  6.718
23 27  7.2 F Bulimia nervosa 20.02  1.64 27.742  7.489
Chu27 2012 62 27 56 F, 6 M Anorexia nervosa 12.9  2 21  7
Haluzik28 1999 17 24.1  3.82 F Anorexia nervosa 15.22  3.06 27  7
Haluzik29 1999 11 23.7  3.1 F Anorexia nervosa 15.4  3.2 28  7
Nova33 2004 14 15.1  2.56 F Anorexia nervosa 9.4  6.3 months 15.24  1.71 26.3  5.6
Pascal46 2002 25 15.6  2.3 F Anorexia nervosa 14.6  2 29.975  5.995
Rigaud35 2009 16 26  9 (all) 115 F, 5 M (all) Anorexia nervosa 11.1  0.65 14  4
35 Anorexia nervosa 13.1  0.5 23  3
35 Anorexia nervosa 15  0.49 27  2
21 Anorexia nervosa 16.8  0.51 31  5
13 Anorexia nervosa 19.5  2.4 28  6
Van Binsbergen38 1988 20 24.7 F Anorexia nervosa 4.9 years 14.4 30.1
Haluzik39 1998 14 F Anorexia nervosa 15.5  2.9 27 7
Cortes42 2005 33 20 F Anorexia nervosa 16.5 20.9
Orgaz43 2004 18 26 F Bulimia nervosa 24.5 22.3
Coles49 2005 8 23 F Fasting bulimia nervosa 22 24
8 23 F Bulimia nervosa 23.3 30

1023.e7
1023.e8 The American Journal of Medicine, Vol 128, No 9, September 2015
Figure 3 Prealbumin and body mass index.
We do not advocate withholding food from people. As in
clinical care, comparator patients in clinical trials of sup-
plemental nutrition should receive attentive efforts to pro-
vide food by mouth ad lib where possible. We suspect that
the presence of hunger will be a very important indicator of
a patient’s ability to benefit from food. We hypothesize that
low serum albumin and prealbumin levels, in contrast,
identify a group of patients who will be unable to benefit
from nutrition support.
In summary, in healthy patients, serum albumin and
prealbumin levels are useless as markers of nutritional sta-
tus: they fail to identify those who are starving. In patients
with significant injury or illness, nutritional assessment is
complex because of the similarities between inflammatory
illness and undernutrition; there is no reason to believe that
these measures identify patients who could benefit from
nutrition support. Meaningful nutrition assessment of pa-
tients who are sick can be developed only when clinical
trials of nutrition support show benefit for particular groups
of patients.
ACKNOWLEDGMENT
The authors thank the Johns Hopkins Bayview medical
librarian, Christine Caulfield-Noll, for her assistance with
conducting the database searches. We also thank the in-
terpreters who helped us translate several of the foreign
language articles.
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APPENDIX
Supplementary materials accompanying this article can be
found in the online version at http://dx.doi.org/10.1016/j.
amjmed.2015.03.032
Lee et al Serum Albumin and Prealbumin During Starvation
APPENDIX 1 SEARCH TERMS BY DATABASE
PubMed
“Starvation”[Mesh] OR “Energy Intake”[Mesh] OR “Mal-
nutrition”[Mesh] OR “Anorexia”[Mesh] OR “Caloric
Restriction”[Mesh] OR “Weight Loss” [Mesh] OR “Protein
Deficiency” [Mesh] OR “Fasting” [Mesh] OR “Food
Deprivation” [Mesh] OR starvation[tiab] OR “energy in-
take*”[tiab] OR malnutrition[tiab] OR anorexi*[tiab] OR
“caloric restriction”[tiab] OR “weight loss”[tiab] OR “pro-
tein deficiency”[tiab] OR “fasting”[tiab] OR “food depri-
vation*”[tiab] OR “low nutrient intake*”[tiab] OR
“nutritional deprivation*”[tiab] OR undernutrition[tiab] OR
malnourish*[tiab] OR “caloric intake*”[tiab] OR “dietary
restriction”[tiab]
AND
“Albumins”[Mesh] OR “Serum Albumin”[Mesh] OR
“Prealbumin”[Mesh] OR albumin*[tiab] OR “serum albu-
min*”[tiab] OR prealbumin*[tiab] OR “serum pre-
albumin*”[tiab] OR transthyretin*[tiab] OR “serum
transthyretin*”[tiab]
AND
“Eating Disorders”[Mesh] OR “Prisoners”[Mesh] OR “Diet,
Reducing”[Mesh] OR “Survival”[Mesh] OR “Acci-
dents”[Mesh] OR “Bariatric Surgery”[Mesh] OR “eating
disorder*”[tiab] OR prisoner*[tiab] OR “reducing di-
et*”[tiab] OR “weight loss diet*”[tiab] OR “weight
reducing diet*”[tiab] OR “weight reduction diet*”[tiab] OR
surviv*[tiab] OR accident*[tiab] OR “bariatric surgery”
[tiab] OR “bariatric surgeries”[tiab] OR famine*[tiab] OR
“hunger strike*”[tiab] OR “stunts”[tiab] OR “self
starvation”[tiab]
Embase
‘Starvation’/exp OR ‘Malnutrition’/exp OR ‘Caloric
Intake’/exp OR ‘Diet Restriction’/exp OR ‘Anorexia’/exp
OR ‘Weight Reduction’/exp OR ‘Protein Deficiency’/exp
OR ‘Food Deprivation’/exp OR starvation:ab,ti OR mal-
nutrition:ab,ti OR ‘caloric intake’:ab,ti OR ‘caloric intakes’:
ab,ti OR ‘diet restriction’:ab,ti OR anorexi*:ab,ti OR
‘weight reduction’:ab,ti OR ‘protein deficiency’:ab,ti OR
‘food deprivation’:ab,ti OR ‘low nutrient intake’:ab,ti OR
‘low nutrient intakes’:ab,ti OR ‘nutritional deprivation’:ab,ti
OR ‘nutritional deprivations’:ab,ti OR undernutrition:ab,ti
OR malnourish*:ab,ti OR ‘energy intake’:ab,ti OR ‘energy
intakes’:ab,ti
AND
‘Albumin’/exp OR ‘Serum Albumin’/exp OR ‘Prealbumin’/
exp OR albumin*:ab,ti OR ‘serum albumin’:ab,ti OR
‘serum albumins’:ab,ti OR prealbumin*:ab,ti OR ‘serum
prealbumin’:ab,ti OR ‘serum prealbumins’:ab,ti OR
1023.e11
transthyretin*:ab,ti OR ‘serum transthyretin’:ab,ti OR
‘serum transthyretins’:ab,ti
AND
‘Eating Disorders’/exp OR ‘Prisoner’/exp OR ‘Low Calory
Diet’/exp OR ‘Survival’/exp OR ‘Accident’/exp OR ‘Bar-
iatric Surgery’/exp OR ‘Hunger’/exp OR ‘eating dis-
order’:ab,ti OR prisoner*:ab,ti OR ‘low calory diet’:ab,ti
OR ‘low calorie diet’:ab,ti OR ‘hypocaloric diet’:ab,ti OR
‘reducing diet’:ab,ti OR surviv*:ab,ti OR accident*:ab,ti OR
‘bariatric surgery’:ab,ti OR ‘bariatric surgeries’:ab,ti OR
‘bariatric procedure’:ab,ti OR ‘bariatric procedures’:ab,ti
OR ‘bariatric operation’:ab,ti OR ‘bariatric operations’:ab,ti
OR hunger:ab,ti OR famine*:ab,ti OR ‘hunger strike’:ab,ti
OR ‘hunger strikes’:ab,ti OR stunts:ab,ti OR ‘self
starvation’:ab,ti
CINAHL
(MH “Starvation”) OR (MH “Malnutrition”) OR (MH
“Energy Intake”) OR (MH “Nutritional Status: Nutrient
Intake (Iowa NOC)”) OR (MH “Restricted Diet”) OR (MH
“Weight Loss”) OR (MH “Protein Deficiency”) OR (MH
“Fasting”) OR TI starvation OR AB starvation OR TI
malnutrition OR AB malnutrition OR TI “energy intake*”
OR AB “energy intake*” OR TI “restricted diet” OR AB
“restricted diet” OR TI “weight loss” OR AB “weight loss”
OR TI “protein deficiency” OR AB “protein deficiency” OR
TI “fasting” OR AB “fasting” OR TI “food deprivation” OR
AB “food deprivation” OR TI “low nutrient intake*” OR
AB “low nutrient intake*” OR TI “nutritional deprivation*”
OR AB “nutritional deprivation*” OR TI undernutrition OR
AB undernutrition OR TI malnourish* OR AB malnourish*
OR TI “caloric intake*” OR AB “caloric intake*” OR TI
anorexi* OR AB anorexi*
AND
(MH “Albumins”) OR (MH “Serum Albumin”) OR TI al-
bumin* OR AB albumin* OR TI “serum albumin*” OR AB
“serum albumin*” OR TI prealbumin* OR AB prealbumin*
OR TI “serum prealbumin*” OR AB “serum prealbumin*”
OR TI transthyretin* OR AB transthyretin* OR TI “serum
transthyretin*” OR AB “serum transthyretin*”
AND
(MH “Eating Disorders”) OR (MH “Prisoners”) OR (MH
“Diet, Reducing”) OR (MH “Diet, Fat-Restricted”) OR (MH
“Diet, Low Carbohydrate”) OR (MH “Restricted Diet”) OR
(MH “Survival”) OR (MH “Accidents”) OR (MH “Bariatric
Surgery”) OR (MH “Bariatric Patients”) OR TI “eating
disorder*” OR AB “eating disorder*” OR TI prisoner* OR
AB prisoner* OR TI “reducing diet*” OR AB “reducing
diet*” OR TI “fat-restricted diet*” OR AB “fat-restricted
diet*” OR TI “low carbohydrate diet*” OR AB “low car-
bohydrate diet*” OR TI “restricted diet*” OR AB “restricted
diet*” OR TI surviv* OR AB surviv* OR TI accident* OR
1023.e12
AB accident* OR TI “bariatric surger*” OR AB “bariatric
surger*” OR TI “bariatric patient*” OR AB “bariatric pa-
tient*” OR TI famine* OR AB famine* OR TI “hunger
strike*” OR AB “hunger strike*” OR TI “stunts” OR AB
“stunts” OR TI “self starvation” OR AB “self starvation”
Cochrane
starvation OR malnutrition OR “energy intake*” OR ano-
rexi* OR “low nutrient intake*” OR “nutritional depriva-
tion*” OR undernutrition OR malnourish* OR “caloric
intake*” OR “dietary restriction” OR “caloric restriction”
OR “weight loss” OR “protein deficiency” OR “fasting” OR
“food deprivation”
The American Journal of Medicine, Vol 128, No 9, September 2015
AND
albumin* OR “serum albumin*” OR prealbumin* OR
“serum prealbumin*” OR transthyretin* OR “serum
transthyretin*”
AND
“eating disorder*” OR prisoner* OR “reducing diet*” OR
survival* OR accident* OR “bariatric surgery*” OR
“weight loss diet*” OR “weight reducing diet*” OR “weight
reduction diet*” OR “low carbohydrate diet” OR “fat
restricted diet” OR “restricted diet” OR famine* OR “hun-
ger strike*” OR stunts OR “self starvation*”
 Lee et al
APPENDIX 2 TABULATED DATA FROM ALL INCLUDED STUDIES

Weight Albumin BMI Weight Albumin Prealbumin

Total Mean Amount/ After After after After After after

Serum Albumin and Prealbumin During Starvation

Study Number Baseline Baseline Baseline Baseline Duration Reason Type Caloric Caloric Nutritional Nutritional Nutritional Nutritional
(First Year of Study of Mean BMI Weight Albumin Prealbumin of Caloric for Caloric of Caloric Restriction Restriction Nutritional Intervention Intervention Intervention Intervention
Author) Study Design Subjects Age (years) Sex (kg/m2) (kg) (g/dL) (mg/dL) Restriction Restriction Restriction (kg) (g/dL) Intervention (kg/m2) (kg) (g/dL) (mg/dL)

Nishida13 2010 Cross- 210 29.9  5.31 F 17.5  4.49  0.2 23.3  3.56 BMI <18.5 but
sectional 0.78 no
anorexia
nervosa
118 32.9  4.29 F 20.7  4.45  0.21 23.1  3.84 Self-reported
3.33 weight loss
>1 kg
Rigaud14 2000 Case 5 29.8  9.3 F 9.77  24.55  3.35  0.28 13  6 Severe 230  57 kcal/ 8 weeks 32.67 
control 0.1 1.64 anorexia day enteral 1.73
nervosa nutrition
16 25.2  3.9 F 13.6  4.05  0.58 31  6 Anorexia 840  8 weeks oral
1.1 nervosa 157 kcal/day intake þ
enteral
nutrition
Bentdal55 1988 Case 33 25 F 39.67 4 31 6 years Anorexia
control nervosa
Chui15 2008 Case 63 21.3  2.3 F 21.8  4.13  0.28 6.5  1.7 Anorexia
control 3.4 years nervosa
49
Coles 2005 Observation 8 23 F 22 24 Fasting
bulimia
nervosa
8 24 F 23.3 30 Bulimia
nervosa
42
Cortes 2005 Observation 33 20 F 16.5 4.6 20.9 Anorexia
nervosa
Dostalova 16
2010 Observation 16 24.9  1.34 F 15.7  4.38  0.112 Anorexia 2 months 17.5  4.76  0.072
0.3 nervosa partial 0.23
refeeding
Dowd56 1983 Cross- 18 24 16 F, 40 3.61  0.5 29.2  8.2 Anorexia
sectional 2M nervosa
Keys50
1950 Randomized 8 25.5  3.47 M (all) 68.32 4.39 24 weeks Conscientious 1543.6 cal/day 51.99 3.925 12 weeks oral 55.42
controlled (all) (all) objectors intake 400
trial (all) cal/day
8 69.41 4.32 1571.0 cal/day 51.74 3.716 12 weeks oral 56.98
intake 800
cal/day
8 72.3 4.219 1619.1 cal/day 54.48 3.888 12 weeks oral 61.72
intake
1200 cal/
day
8 67.51 4.178 1544.3 cal/day 52.09 3.919 12 weeks oral 60.91
intake
1600 cal/
day
Gendall17 1999 Case 152 25.9  6.0 F 23.0  4.87  3.4 27  5 71.1  Bulimia
control 2.7 65.6 nervosa
months
Gentile18 2011 Cross- 298 19.8  6.1 278 F, 14.6  4.8  0.5 Anorexia
section 20 M 2.1 nervosa,

1023.e13
eating
disorder
NOS
 1023.e14
Continued

Weight Albumin BMI Weight Albumin Prealbumin

Total Mean Amount/ After After after After After after
Study Number Baseline Baseline Baseline Baseline Duration Reason Type Caloric Caloric Nutritional Nutritional Nutritional Nutritional
(First Year of Study of Mean BMI Weight Albumin Prealbumin of Caloric for Caloric of Caloric Restriction Restriction Nutritional Intervention Intervention Intervention Intervention
Author) Study Design Subjects Age (years) Sex (kg/m2) (kg) (g/dL) (mg/dL) Restriction Restriction Restriction (kg) (g/dL) Intervention (kg/m2) (kg) (g/dL) (mg/dL)

Haluzik40 1998 Case 14 F 15.5  42.7  4.863  0.264 27  7 Anorexia

control 2.9 1.83 nervosa
Hildebrandt 19
2001 Case 28 13.7  4.86  0.73 5.0  4.2 Anorexia
control 2.3 years nervosa
24 19.1  4.75  0.62 6.7  5.5 Bulimia
3.7 years nervosa
Hukshorn 51
2003 Randomized 12 34.9  1.3 M 28.6  95.0  4.08  0.06 46 days Semi- 2.1 MJ/days 80.4  2.4 4.03 
controlled 0.5 3.2 (all) starvation (all), 0.09
trial in placebo
overweight
pts (all)
12 34.6  1.2 M 28.9  97.1  4.13  0.05 Leptin 85.3  0.9 4.05 
0.4 1.8 0.07
20
Mukamel 2001 Case report 1 13.5 F 11.25 4.7 10 months Anorexia
nervosa
Murciano 21
1994 Cohort 15 24.9  8.7 F 13.5  37.1  3.99  0.21 24  4 12 months Anorexia 8 weeks oral 42.9 
1.1 4.7 nervosa intake and 4.6
enteral
nutrition
Narayanan57 2010 Case report 1 34 F 10.7 32 4.7 17 years Anorexia Oral intake 36.8 3
nervosa 137 kcal/
days

The American Journal of Medicine, Vol 128, No 9, September 2015

1 26 F 11.2 31.5 5.1 8 years Anorexia <400 kcal/days Oral intake 33.3 2.4
nervosa 400 kcal/
days
Orgaz43 2004 Observation 18 26 F 24.5 4.24 22.3 Bulimia
nervosa
Rodrigues 2010 Case control 11 15.0  0.5 F 15.1  4.7  0.1 Anorexia
Pereira22 0.6 nervosa
Silvetti58 1998 Cross-section 23 15 F 14.2 4.6 (median) Anorexia
nervosa
Symreng59 1985 Cohort 10 14-18, 34 F 36.5  4.3  0.4 25  7 Anorexia Total 46.0  4.5 4.4  0.5 29  6
3.1 nervosa parenteral
nutrition,
oral diet
Tey60 2005 Case report 1 19 F 36.6 4.3 Anorexia
nervosa
Varela23 1991 Case control 17 15.68  F 14.67  38.64  4.41  0.06 40  10 1.54  Anorexia
0.95 0.27 0.94 0.21 nervosa
years
19 18.47  F 17.93  47.34  4.20  0.08 50  10 3.80  Anorexia
0.75 0.25 1.55 0.54 nervosa
years
Vogele47 2009 Case control 8 23.2  3.1 F 22.0  24.0  5.1 5.5  Fasting
3.1 4.1 bulimia
years nervosa
9 24.5  8.5 F 23.3  30.1  6.3 5.5  Nonfasting
3.3 4.1 bulimia
years nervosa
Zastrow24 2011 Case report 1 26 F 10.5 2.95 14 years Anorexia 60 days 13.2
nervosa enteral
nutrition
Agnello25 2012 Case control 39 26  9 F 13.9  37.5  4.6  0.6 26.3  7.4 60 months Anorexia
2 6 (median) nervosa
 Lee et al
Continued

Weight Albumin BMI Weight Albumin Prealbumin

Total Mean Amount/ After After after After After after
Study Number Baseline Baseline Baseline Baseline Duration Reason Type Caloric Caloric Nutritional Nutritional Nutritional Nutritional
(First Year of Study of Mean BMI Weight Albumin Prealbumin of Caloric for Caloric of Caloric Restriction Restriction Nutritional Intervention Intervention Intervention Intervention

Serum Albumin and Prealbumin During Starvation

Author) Study Design Subjects Age (years) Sex (kg/m2) (kg) (g/dL) (mg/dL) Restriction Restriction Restriction (kg) (g/dL) Intervention (kg/m2) (kg) (g/dL) (mg/dL)

Barbe48 1993 Case control 12 16-31 F 13.8  25  2 6 months-4 Anorexia Oral intake 17.1  0.2 30  1
0.5 years nervosa
Bufano 62
1990 Cohort 9 F 34.51  4.3  0.6 21.9  6 17  14 Anorexia Oral intake þ 39.8  3.3 4.0  0.4 27.9  4.6
4.48 months nervosa, enteral
reduced nutrition
intake and
weight loss
Caregaro26 2001 Cohort 59 22.6  7.1 F 14.87  4.582  0.578 27.924  Anorexia 1078.58  Oral intake 13.8  2 to
1.89 6.718 nervosa 708.27 þ enteral 14.9  1.7
kcal/days nutrition, (20 pts)
oral
intake þ
oral
nutrition
supplement
23 27  7.2 F 20.02  4.433  0.511 27.742  Bulimia 2393.44 
1.64 7.489 nervosa 3053.33
kcal/days
Caughey63 1970 Case report 1 18 M 35 4.8 Lack of access 9 months high 45
to food protein
diet þ iron
Chu27 2012 Cohort 62 27 56 F, 12.9  76.1  3.7  0.7 21  7 Anorexia Oral intake 13.1  1.9
6M 2.0 14.4 nervosa
Dekaris64 1993 Case control 29 48 (median) M 69.5 4.5 4-7 months Prisoners
(median)
Dubois44 2011 Observation 8 32.6 1 F, 21 3.9 57 days Hunger Total starvation,
7M strikers water only
Goodnight52 1985 Clinical trial 10 30.6 5 F, 76.49 4.4  0.3 4 days Fasting Multivitamin 72.59 4.8  0.3
5M and water or
weak tea
Gorsane65 2007 Observation 1 29 M 69 1 month Hunger striker Total 59 3.5
starvation
Haluzik28 1999 Case control 17 24.1  3.82 F 15.22  4.903  0.602 27  7 Anorexia
3.06 nervosa
Haluzik29 1999 Case control 11 23.7  3.1 F 15.4  43.1  4.93  0.28 28  7 Anorexia Oral intake 17.2  3.0 47.9  8.4 4.04  0.624 33  9
3.2 8.5 nervosa
Hertlova66 1994 Clinical trial 5 23.4 13.1 34.6 3.25 Anorexia 3057-3828 kJ Total 40.2 3.5
nervosa parenteral
nutrition
Herzog30 1997 Cohort 66 20.8 F 13.7 4.171  0.552 Anorexia Enteral 19.3
nervosa nutrition,
total
parenteral
nutrition
Krantz31 2005 Case report 1 52 F 17 49 4 20 years Anorexia
nervosa
Lawson32 2009 Case control 10 27.5  2.4 F 18.3  49  1.2 4.7  0.1 Anorexia
0.3 nervosa
(all)
10 25.8  1.1 F 18.0  48.6  4.4  0.1
0.4 1.5

1023.e15
 1023.e16
Continued

Weight Albumin BMI Weight Albumin Prealbumin

Total Mean Amount/ After After after After After after
Study Number Baseline Baseline Baseline Baseline Duration Reason Type Caloric Caloric Nutritional Nutritional Nutritional Nutritional
(First Year of Study of Mean BMI Weight Albumin Prealbumin of Caloric for Caloric of Caloric Restriction Restriction Nutritional Intervention Intervention Intervention Intervention
Author) Study Design Subjects Age (years) Sex (kg/m2) (kg) (g/dL) (mg/dL) Restriction Restriction Restriction (kg) (g/dL) Intervention (kg/m2) (kg) (g/dL) (mg/dL)

McMurray53 1985 Clinical trial 6 20-31 M 70.48  4.4  0.1 1 week Research 1363  68.32  4.6  0.1
3.66 135 kcal/ 3.47
days
Mira67 1987 Case control 61 25  5.5 F 60.4  4.82  0.34 (all) Bulimia
10.7 nervosa
22 27.5  6.9 F 41.4  Anorexia
6.2 nervosa
7 25.1  6.0 F 56.7  Atypical eating
19.6 disorder
Narayanan 68
2009 Case report 1 34 F 11 36 3.5 Several Anorexia <400 kcal/days Total 35.2 3.15
weeks nervosa parenteral
nutrition
1500
kcal/days
Nova33 2004 Cohort 14 15.1  2.56 F 15.24  39.4  4.51  0.69 26.3  5.6 9.4  Anorexia Inpatient 17.34  1.97 45.2  6.7 4.77  0.45 25.8  6.8
1.71 6.1 6.3 nervosa
months
Okabe45 1993 Cohort 12 19.25 11 F, 27.7 4.1 2.28 years Anorexia Inpatient 31.1 3.5
1M nervosa
Olubodun 34
1996 Case control 81 27.7  5.9 M 20  2.7 3.66  0.63 229.1  Prisoners
210.1
days

The American Journal of Medicine, Vol 128, No 9, September 2015

Pascal46 2002 Case control 25 15.6  2.3 F 14.6  2 0.67  0.06 nmol/ 5.45  1.09 Anorexia 30 days oral 17.2  1.4 0.67  0.06 6.36  1.45
L (0.00000489 mmol/L nervosa intake nmol/L mmol/L
 (29.975 (0.00000489  (34.98 
0.000000402  5.995 0.000000402 7.975
g/dL)* g/dL) g/dL)* mg/dL)
Pertschuk69 1982 Cohort 22 23.3  5.5 21 F, 32.9  4.3  0.7 Anorexia
1M 5.3 nervosa
Richard70 1983 Clinical trial 8 23 F 36.3 3.9 27.6 Anorexia Oral intake, 43.2 36.6
nervosa oral
intake þ
enteral
nutrition
Rigaud71 1989 Observation 23 26 24 F, 37.7 4.4 29 Anorexia
2M nervosa
Rigaud35 2009 Case control 16 26  9 (all) 115 F, 11.1  3.24  0.51 14  4 Anorexia
5M 0.65 nervosa
(all) (all)
35 13.1  4.02  0.69 23  3
0.5
35 15  4.18  0.63 27  2
0.49
21 16.8  4.34  0.64 31  5
0.51
13 19.5  4.11  0.72 28  6
2.4
Rock36 1995 Cohort 13 26  8 12 F, 17.4  4.1  0.5 6.4  3.3 Anorexia Oral intake
1M 2.9 years nervosa,
bulimia
nervosa
Roijen41 1991 Cross-section 20 13.3 17 F, 14.7 34.9 4.58079 Anorexia
3M nervosa
 Lee et al
Continued

Weight Albumin BMI Weight Albumin Prealbumin

Total Mean Amount/ After After after After After after
Study Number Baseline Baseline Baseline Baseline Duration Reason Type Caloric Caloric Nutritional Nutritional Nutritional Nutritional
(First Year of Study of Mean BMI Weight Albumin Prealbumin of Caloric for Caloric of Caloric Restriction Restriction Nutritional Intervention Intervention Intervention Intervention

Serum Albumin and Prealbumin During Starvation

Author) Study Design Subjects Age (years) Sex (kg/m2) (kg) (g/dL) (mg/dL) Restriction Restriction Restriction (kg) (g/dL) Intervention (kg/m2) (kg) (g/dL) (mg/dL)

Rolla72 1967 Observation 9 (all) F 38.8 3.35 Anorexia

nervosa
F 46.4 3.64 Constitutional
thinness
Russell 73
1983 Cohort 6 23.8  2 5 F, 1 M 38.8  4.3  1 Anorexia 8 weeks oral 46.5  4.4 4.4  0.3
3.3 years nervosa intake
Smith37
1996 Case control 6 27.2  2.36 F 15.35  38.8  3.7  0.193 Anorexia
0.694 2.43 nervosa
Thibault 74
1987 Cohort 25 18  5 24 F, 35.1  5.8  1.2 18 months Anorexia 773  349 kcal/
1M 6.9 nervosa days
Vaisman 54
1990 Clinical trial 4 41.25 3 F, 1 M 24.58 69.5  3.7  0.3 6 days Very low 200 kcal/days 65.4  8.9 3.8  0.2
9.3 calorie diet
Van 1988 Case control 20 24.7 F 14.4 39.6 4.07 30.1 4.9 years Anorexia 1090 kcal/days
Binsbergen38 nervosa
75
Yap 1975 Case control 3 35.67 F 35.3 3.543
Jackson61 2006 Case report 1 30 M 28.36 96 44 days Personal Water only 65.4  8.9 5.29
endurance
Faintuch 39
2001 Observation 8 43.3  6.2 1 F, 7 M 21.5  66.4  3.4  0.3 43 days Hunger Water only, Intravenous 23.0  2.4 71.4  7.5 3.2  0.2
2.6 6.6 strikers occasional fluids þ
multivitamin oral intake
and
electrolytes

APPENDIX 3 ALBUMIN AND BODY MASS INDEX (BMI) BEFORE AND AFTER NUTRITIONAL INTERVENTION

Reason for Duration of BMI (kg/m2)  SD Albumin (g/dL)  SD Type of BMI (kg/m2)  SD Albumin (g/dL)  SD
Study # of Nutrition Nutrition Before Nutritional Before Nutritional Nutritional After Nutritional After Nutritional
(First Author) Year Subjects Age (years) Sex Restriction Restriction Intervention Intervention Intervention Intervention Intervention
Dostalova16 2010 16 24.9  1.34 F
Anorexia 15.7  0.3 4.38  0.112 Partial refeeding 17.5  0.23 4.76  0.072
nervosa (2 months)
Haluzik29 1999 11 23.7  3.1 F Anorexia 15.4  3.2 4.93  0.28 Refeeding (30 days) 17.2  3 4.04  0.624
nervosa
Nova33 2004 14 15.1  2.56 F Anorexia 9.4  15.24  1.71 4.51  0.69 Inpatient rehab 17.34  1.97 4.77  0.45
nervosa 6.3 months
Faintuch39 2001 8 43.3  6.2 1 F, 7 M Hunger 43 days 21.5  2.6 3.4  0.3 Intravenous fluid 23  2.4 3.2  0.2
strikers (2 days), then oral diet

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APPENDIX 4 ALBUMIN AND BODY MASS INDEX BEFORE AND AFTER NUTRITIONAL INTERVENTION.
DOSTALOVA ET AL,16 HALUZIK ET AL,29 NOVA ET AL,33 FAINTUCH ET AL.39
 Lee et al
APPENDIX 5 PREALBUMIN AND BODY MASS INDEX (BMI) BEFORE AND AFTER NUTRITIONAL INTERVENTION

Serum Albumin and Prealbumin During Starvation

Prealbumin Prealbumin
Reason for Duration of BMI (kg/m2)  SD (mg/dL)  SD BMI (kg/m2)  SD (mg/dL)  SD
Study # of Nutrition Nutrition Before Nutritional Before Nutritional Type of Nutritional After Nutritional After Nutritional
(First Author) Year Subjects Age (years) Sex Restriction Restriction Intervention Intervention Intervention Intervention Intervention
Barbe48 1993 12 16-31 F Anorexia nervosa 6 months-4 years 13.8  0.5 25  2 Oral diet (40  5 days) 17.1  0.2 30  1
Haluzik29 1999 11 23.7  3.1 F Anorexia nervosa 15.4  3.2 28  7 Refeeding (30 days) 17.2  3 33  9
Nova33 2004 14 15.1  2.56 F Anorexia nervosa 9.4  6.3 months 15.24  1.71 26.3  5.6 Inpatient rehab 17.34  1.97 25.8  6.8
Pascal46 2002 25 15.6  2.3 F Anorexia nervosa 14.6  2 29.975  5.995 Refeeding (30 days) 17.2  1.4 34.98  7.975

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APPENDIX 6 PERALBUMIN AND BODY MASS INDEX BEFORE AND AFTER NUTRITIONAL INTERVENTION.
BARBE ET AL,48 HALUZIK ET AL,29 NOVA ET AL,33 PASCAL ET AL.46
APPENDIX 7 ALBUMIN AND WEIGHT BEFORE AND AFTER NUTRITION RESTRICTION

Lee et al
Albumin

Serum Albumin and Prealbumin During Starvation

Weight Before Albumin (g/dL)  SD Duration of Weight after (g/dL)  SD
Study # of Nutrition Before Nutrition Type of Nutrition Nutrition Nutrition After Nutrition
(First Author) Year Subjects Age (years) Sex Restriction (kg) Restriction Restriction Restriction Restriction (kg) Restriction
Keys50 1950 8(1) 25.5  3.47 (all) M 68.32 4.39 1543.6 kcal/day 24 weeks (all) 51.99 3.925
8(2) M 69.41 4.32 1571 kcal/day 51.74 3.716
8(3) M 72.3 4.219 1619.1 kcal/day 54.48 3.888
8(4) M 67.51 4.178 1544.3 kcal/day 52.09 3.919
Hukshorn51 2003 12(1) 34.9  1.3 M 95  3.2 4.08  0.06 2.1 MJ/day 46 days (all) 80.4  2.4 4.03  0.09
12(2) 34.6  1.2 M 97.1  1.8 4.13  0.05 2.1 MJ/day 4 days 85.3  0.9 4.05  0.07
Goodnight52 1985 10 30.6 5 F, 5 M 76.49 4.4  0.3 MVI, water or weak tea 72.59 4.8  0.3
McMurray53 1985 6 20 - 31 M 70.48  3.66 4.4  0.1 1363  135 kcal/day 1 weeks 68.32  3.47 4.6  0.1
Vaisman54 1990 4 41.25 3 F, 1 M 69.5  9.3 3.7  0.3 200 kcal/day 6 days 65.4  8.9 3.8  0.2

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1023.e22 The American Journal of Medicine, Vol 128, No 9, September 2015

APPENDIX 8 ALBUMIN AND WEIGHT BEFORE AND AFTER NUTRITIONAL RESTRICTION. KEYS ET AL,50
HUKSHORN ET AL,51 GOODNIGHT ET AL,52 MCMURRAY ET AL.53