Nutrition Support
pp
in the Obese
Patient
David Frankenfield,
Frankenfield MS,
MS RD
Chief Clinical Dietitian
Department of Clinical Nutrition
Penn State Milton S. Hershey Medical Center
Presentation Outline
1. Obesity ≠ adequate nutrition
2. Early feeding principles apply
3. Is hypocaloric feeding a good idea?
4. How do we know what the needs are?
1.Obesity ≠ adequate nutrition
• The critical body compartment to
support the inflammatory response is
the body protein compartment.
• Obesity is excess body fat.
• Diet q
quality
y in obesity
y is often p
poor
(low intake of vitamins, minerals, etc).
1.Obesity ≠ adequate nutrition
In mobile, healthy obese people, there is a
“training
training effect”
effect of carrying excess body weight
weight.
In fact, obesity seems to be a survival advantage
during critical illness. Hormone release from
adipose tissue? Larger protein mass? Other?
Body weight and fat free mass in obese people
Total weight = Body fat + Fat-free
Fat free mass
200
Mass ((kg)
175
At BMI 20 and wt 50 kg,
FFM is 40 kg or 80% of wt.
150
125
At BMI 25 and wt 75 kg,
FFM is 56 kg or 75% of wt.
100
75
At BMI 45 and wt 200 kg,
FFM falls
f
to 50%
0% off wt but
total FFM is 100 kg
50
25
20
25
30
35
40
45
Body mass index (kg/m2)
Data from Frankenfield DC, et al. Limits of body mass
index to detect obesity. Nutrition. 1999.
Exceptions
Sarcopenic Obesity
•Aging
•Hypokinesis (no physical activity)
•Prolonged illness (inflammation plus hypokinesis)
•Don’t make assumptions about the nutritional status
of obese people.
Exceptions
Sarcopenic Obesity
•Aging
•Hypokinesis (no physical activity)
•Prolonged illness (inflammation plus hypokinesis)
•Don’t make assumptions about the nutritional status
of obese people.
2. Early feeding principles apply
• Ob
Obese critically
iti ll ill patients
ti t should
h ld nott b
be
expected to live off their excess weight
• Early feeding concept in critical care is
not dependent on nutritional status.
General enteral nutrition recommendations
Route
Timing
Grade
ADA (2005)
Enteral 24 – 48 hr
I of V
ASPEN (2009)
Enteral 24 – 48 hr
C of E
Canada (2003)
Enteral 24 – 48 hr
Minor uncertainty
Recommend
ESPEN (2006)
Enteral <24 hrs
C of D
3. Is hypocaloric feeding a good idea?
Theory: Lower energy burden reduces oxidative
stress, improves glucose control, reduces fluid
intake wt loss improves respiratory function and
intake,
nursing care.
Conclusion
Grade
ADA 2005 Consider hypocaloric feeding III of V
ASPEN/CCM Achieve 50-65% of target
C of E
2009 calories in first week (obese).
N recommendation
No
d ti
Canada 2003
None
Don t exceed 20
Don’t
20-25
25 kcal/kg
ESPEN 2006 (eucaloric)
C of D
3. Is hypocaloric feeding a good idea?
Underfeeding is Good
Hise ME. J Am Diet Assoc. 2007. Prospective,
observational study. 25-35 kcal/kg general goal.
Mean calorie intake >82% (mean 21 vs
vs. 11
kcal/kg) of goal doubled the ICU LOS (11 vs. 24
days) and hospital LOS (22 vs. 47 days). Were
th
these
patients
ti t hyperglycemic?
h
l
i ? N
Nott kknown. W
Was
IV lipid intake different? Not known.
3. Is hypocaloric feeding a good idea?
Underfeeding
g is Good
Kca
al/kg body
y wt
Krishnan JA. Chest. 2003. Prospective, observational study.
BMI<30. Intake split into tertiles (I=0-32% of goal, II=33-65% of
goal III=>66% of goal).
goal,
goal) Tertile II was more likely than Tertile I to
wean from ventilator. Tertile III was more likely than Tertile I to die
and less likely to wean from ventilator. Tertile II actual intake was
9 18 kcal/kg).
9-18
kcal/kg)
3. Is hypocaloric feeding a good idea?
Underfeeding is Bad
Villet S
S. Clinical Nutrition
Nutrition, 2005: Prospective,
Prospective
observational study. Calorie deficit at 7 days and
cumulatively, was associated with more infection
and total complications, and longer ICU stay. Better
association than found with SAPS or SOFA. No
correlation with mortality.
3. Is hypocaloric feeding a good idea?
Underfeeding is Bad
Hartl R. J Neurosurg 2008: Prospective observational study. In
traumatic brain injured patients, Patients not fed within 5-7 days had
a 2- and 4-fold increase in likelihood of death by 2 weeks. Every 10
kcal/kg deficit from goal (25 kcal/kg) was associated with a 30-40%
increase in mortalityy rate.
Anbar R. JPEN(ESPEN),
(
), 2009/2010 (abstract).
(
) Prospective,
p
,
randomized study (calorimetry vs. ACCP guideline 25 kcal/kg).
Calorimeter group had a higher cumulative energy balance (186 vs.
-366
366 kcal/day), stayed in ICU longer (18.6 vs. 13.3 days), had
similar ICU mortality (21 vs. 27%) but lower hospital mortality (29
vs. 48%). Calorimeter group got more TPN.
4. How do we know what the needs are?
Accuracy Rate (+10% of measured)
Equation
Mifflin
PSU
S (Mifflin)
( ff )
Modified
Younger Younger
Older
Older
All Nonobese Obese Nonobese Obese
(202)
(52)
(47)
(52)
(51)
25
67
73
23
69
-
21
70
-
21
77
-
35
53**
74
Mifflin: Wt(10) + Ht(6.25) – Age(5) + Male(5) – Female(161)
PSU: RMR = Mifflin(0.96) + Tmax(167) + Ve(31) – 6212
*
Modification based on these 51 subjects:
RMR=Mifflin(0.71) + Tmax(85) + Ve(64) - 3085
Protein
• General agreement that protein needs are
elevated in critically ill patients.
• No general agreement as to how elevated.
ASPEN/SCCM recommendation
d ti
for protein intake for obesity
(Grade D and E)
• 1.2 g/kg to 2.0 to 2.5+ g/kg (depending on
obesity class. Ideal weight in the obese).
• < 2.0 g/kg body wt for non-obese
• >2.0
>2 0 g/kg
/k id
ideall wtt ffor BMI 30
30-40
40 kkg/m
/ 2
• >2.5 g/kg ideal wt for BMI>40 kg/m2
P
Protein
intake
e (g/dayy)
Protein Recommendation Using ASPEN
y
Guidelines for Obesity
2.0 g/kg 2.5 g/kg
ideal wt ideal wt
ASPEN/SCCM method
Ht 183 cm
Ideal wt 83 kg
BMI (kg/m2)
80 100 120 140 160 180 Body wt (kg)
80 88 93 98 103 108 Adjusted wt (kg)
Summary
Nutrition support in the critically ill obese patient
• Excess weight does not buy the
patient more “NPO”
NPO time
• Early enteral feeding is standard care
and not dependent on nutrient stores.
• Unclear whether a hypocaloric
strategy should be employed.
• Metabolic
M t b li needs
d can b
be estimated
ti t d
fairly reliably.