Nutrition Support &

Management in the
Hospitalized Obese Patient
A L I S O N A T K I N S
M A R C H 1 2 , 2 0 1 4

Presentation Outline
y Overview of obesity: The Basics
y Medical and metabolic effects of obesity
y A.S.P.E.N Grading System

y A.S.P.E.N. Clinical Guidelines: Nutrition Support in

Hospitalized Patients With Obesity

y Role of the Dietitian
y Summary and Take Home Message

Learning Objectives
y Discuss overview of obesity, its definition, incidence and
y

y
y

prevalence
Discuss the co-morbid conditions associated with obesity
that may complicate the critical care/Medical Nutrition
Therapy needed in this population
Identify the common challenges a clinician may face
when providing care to critically ill obese patients
Discuss application of the GRADE System to A.S.P.E.N.
Clinical Guidelines.
Discuss the A.S.P.E.N. Clinical Guidelines: Nutrition
Support of Hospitalized Patients With Obesity

Obesity: Definition, Incidence and Prevalence

y Obesity can be defined as a proportion of body

weight that is adipose tissue (percent body fat) that

is greater than some standard.2
{

{
{

Obesity Class I: BMI of 30.0-34.9 kg/m2

Obesity Class II: BMI of 35.0-39.9 kg/m2
Obesity Class III: BMI greater than 40 kg/m2

y Based on the National Health and Nutrition

Examination Survey 2009-20101

{
{

RIDGXOWPHQDUHREHVHZLWKD%0,NJP
RIDGXOWZRPHQDUHREHVHZLWKD%0,
kg/m2

Obesity: Definition, Incidence and Prevalence1

y As of June 2013, the American Medical Association

recognized obesity as a disease that requires

treatment.

y Dietitians are encountering an increased number
of obese patients who require nutrition support
during hospitalization.
A.S.P.E.N. has addressed this problem and recently
published guidelines for this population.
{

Activity Time!
y Close your eyes and imagine a patient:
{ Nutrient deficiencies
{ Lean tissue wasting
{ Refeeding Risk

y Who do you see?!


Medical and Metabolic Effects of Obesity
y Associated with more than 60 comorbid medical conditions.
{ Diabetes
{ Hyperlipidemia
{ Sleep apnea
{ Hypercapnia
{ Congestive heart failure
{ Nonalcoholic fatty liver disease

y Under stress conditions, obese patients may not be able to

take advantage of their abundant fat stores prior to initiation

of nutrition support.3
{
{

Have to depend on endogenous glucose synthesized from the breakdown

of body protein.
Likely short lived. 15

Critical Care Challenges Associated With Obesity4

Respiratory

Mechanics of breathing
CO2 retention
Obstructive Sleep Apnea
Aspiration pneumonia
Pulmonary embolism/deep vein thrombosis

Vascular

Increased blood volume, cardiac output, stroke volume

Decreased left ventricular contraction

Enteral Access Difficulty placing at bedside and difficulty confirming location

Weight limits for fluoroscopy tables and endoscopy suites
Imaging

Weight limits for CT scans, magnetic resonance imaging,

fluoroscopy and interventional radiology.

General
Patient Care

Changing bed linens, bathing, bowel movements

Clean skin/wound care
Transporting patient out of the ICU
Lack of equipment (beds, lifts, chairs)
Number of staff require to move patient in bed
Injuries to nursing and other staff from moving/lifting

Nutrition Support Clinical Guideline Recommendations in

Adult Patients With Obesity1


A.S.P.E.N. Clinical Guidelines: Applying the GRADE System
The Quality of Evidence and Definitions5
Quality

Definition

High

Further research is very unlikely to change our confidence

in the estimate of effect.

Moderate

Further research is likely to have an important impact on

our confidence in the estimate of effect and may change
estimate

Low

Further research is very likely to have an important impact

on our confidence in the estimate of effect and is likely to
change the estimate.

Very Low

Any estimate of effect is very uncertain.

A.S.P.E.N. Clinical Guidelines: Applying the GRADE System

Developing the Grading and Clinical Guideline
Recommendation5

Quality of
Evidence

Weighing Risks GRADE

vs. Benefits
Recommendati
on

Clinical
Guideline
Statement

High to very low

Net benefits
outweigh harms

Strong

We recommend

High to very low

Tradeoffs for
patient are
important

Weak

We suggest

High to very low

Uncertain
tradeoffs

Further research
needed

We cannot make a
recommendation
at this time.

A.S.P.E.N. Clinical Guidelines: Nutrition Support

of Hospitalized Patients With Obesity
Do clinical outcomes vary across levels of obesity in
critically ill or hospitalized non-ICU patients?
2. How should energy requirements be determined in
obese critically ill or hospitalized non-ICU patients?
3. Are clinical outcomes improved with hypocaloric,
high protein diets in hospitalized patients with
obesity?
4. In obese patients who have malabsorptive or
restrictive surgical procedures for weight loss, what
micronutrients should be evaluated?


1.

1. Do clinical outcomes vary across levels of obesity in

critically ill or hospitalized non-ICU patients?1
y 1a. Critically ill patients with obesity experience more

complications than patients with optimal BMI levels.

Nutrition assessment and development of a nutrition
support plan is recommended within 48 hours of ICU
admission (Strong).
{

Evidence grade: low

y 1b. All hospitalized patients, regardless of BMI, should

be screened for nutrition risk within 48 hours of

admission, with strong assessment of patients who are
considered at risk (Strong).
{

Evidence grade: low

Table 1: Do Clinical Outcomes Vary Across Levels of Obesity in Critically ill or

Hospitalized Non-ICU Patients?1

Comparison Outcome

Quantity, Findings
Type of
Evidence

Grade for
outcome

ICU Patients:
Obese vs. optimal
BMI

Mortality (large
studies)

8 OBS

1 increased21
5 decreased 23, 35, 42, 44, 45
2 no difference 32, 46

Low

Hospital LOS
(large studies)

4 OBS

3 increased 22, 29, 45

1 no difference46

Low

Complications

6 OBS

5 increased25, 37, 46-48

1 no difference32

Low

Mortality (large
studies)

4 OBS

1 decreased44
3 no difference22, 23,45

Low

Hospital LOS
(Large studies

4 OBS

2 increased22,29
2 no difference45,46

Low

Mortality

2 OBS

1 increased49
1 no difference91

Low

ICU Patients: BMI

NJPvs
optimal BMI

Non-ICU Patients:
Obese vs. Optimal
BMI

Complications in Obese ICU Patients

y Obesity has shown to be an independent risk factor for

nosocomial infection after trauma6 and in particular

ICU-acquired catheter and blood stream infections7

Reasons not known but may be associated with6

| Prolonged immobility after trauma: leading to prolonged use of
urinary catheters
| Difficult IV access leading to use of central lines for prolonged
periods of time.
| Increased number of ventilator days- increases risk of pneumonia.
| Hyperglycemia/insulin resistance characteristic may depress
resistance to infection.

y These complications may impact nutritional status, and

therefore, early nutrition assessment (as for all critically

ill patients) and care is indicated in this population.

Clarifying the Risks Associated with Varying Levels of

Obesity in Hospitalized ICU and Non-ICU Patients

More prospective, adequately powered outcomes research is

needed.1

Studies that include measures of inflammation, body

composition (with a focus on lean body mass), and micronutrient
status.

Nutrition support interventions that aim to improve clinical

outcomes. 15
Wound healing
| Successful weaning from the ventilator
| Recovery from or lack of infectious complications
| Successful Ambulation
| Discharge from the ICU
| Survival

|

2. How should energy requirements be determined in obese

critically ill or hospitalized non-ICU patients?1

y 2a. In the critically ill obese patient, if indirect

calorimetry is not available, energy requirements

should be based on the Penn State University 2010
predictive equation or the modified Penn State
University (PSU) equation if the patient is over the age
of 60 years (strong).
{

Evidence grade: Strong

y 2b. In the hospitalized obese patient, if indirect

calorimetry is unavailable and the Penn State

University equations cannot be used, energy
requirements may be based on the Mifflin-St. Jeor
equation using actual body weight (weak)
{

Evidence grade: Moderate

The PSU Predictive Equation1

y PSU predictive equation most accurately predicts REE compared

with others including Harris-Benedict, Mifflin St. Jeor,

Swinamer, and Ireton Jones.
{

In the ventilator dependent obese patient

y PSU equation for younger obese patients

{ RMR (kcal/d)= MSJ (0.96) + Tmax (167) +VE (31)-6212
y PSU equation for older obese patients:
{ RMR (kcal/d)= MSJ (0.71) + Tmax (85) +VE (64)-3085

{ MSJ= Mifflin St. Joer Equation
|
|

{
{

Men (kcal/day)= 5 +10 x weight (kg) +6.25 x Ht (cm) -5 x Age (y)

Women (kcal/day)= -161 +10 x weight (kg) +6.25 x Ht (cm)- 5 x age (y)

VE= Minute ventilation (L/minute)

Tmax= maximum temperature in prior 24 hours in degrees C

Where do you find VE in Epic?

Most recent respiratory therapy note.
Under doc flowsheets: adult ventilator template.

Where do you find Tmax in Epic?

Go to patient summary

0D\QHHGWRZUHQFKLQYLWDOVJUDSK
Switch to 24 hour

Predicting REE in Non-Ventilated Mixed ICU and Non-ICU

Patients1
y Harder to assess

Available research (5 studies reviewed):

Multiple predictive equations were compared (Harris-
Benedict, Schofield, Mifflin St. Joer, and others).
| The same predictive equations were not used in each
study.
Small sample of obese subjects
{ Accuracy of REE varied
Error for MSJ lower than Harris Benedict using actual
body weight.
{

Indirect Calorimetry
y Measures resting energy expenditure.
{ 7KH*ROG6WDQGDUG
{ However:
No good evidence that in an ICU patient, energy
requirements based on the REE provides superior
clinical outcomes.
Calorie expenditure can vary substantially from day to

day.
Most patients in the ICU setting are not receiving full
order on tube feeding due to interruptions in feeding.

Prevention of Overfeeding in Obese Patients

y Extremely Important!!!
{ To prevent and/or avoid worsening of hyperglycemia, hyperlipidemia,
hypercapnia, fluid overload, and hepatic fat accumulation. 15
y Aggressive nutrition support will result in increased CO2

production. This May further increase the respiratory work

and impair weaning of the ventilator dependent patient with
obesity.8
y Excessive caloric intake promotes lipogenesis causing hepatic
steatosis and hepatic dysfunction.8
Concern in the obese population due to preexisting higher incidence of fatty liver.

y Important to look at additional sources of calories patient may

be receiving.
{
{

Propofol
D5 containing IV fluids.

Adult Nutrition Support Guidelines at UVA

y Patients who are 130% of IBW
Use Adjusted Body weight to determine energy needs.
15-20 kcal/kg AdjWT

Example Calculation
y

65 Year Old Obese Female Ventilated Patient

{ Admit weight: 103 kg
{ Height: FP
{ IBW: 63.6 kg (162%)
{ Adj wt: 74 kg
{ Minute Volume: 6.4 l/min (01/29 0806)
{ Tmax (1/29): 37.3C
{ PSU Equation (for age >60): 1441 kcal= REE
{ Using 15-20 kcal/kg adjusted weight: 1110-1500 kcal/day
{ RD note recommendations: 1300-1700 kcals daily (18-23 kcals/kg adj)

Order: Promote @60 mL/hr with 2 packets of prosource= 1440

kcal/day

3. Are clinical outcomes improved with hypocaloric, high

protein diets in hospitalized patients with obesity?1
y 3a. Clinical outcomes are at least equivalent in patients supported

with high protein hypocaloric feeding to those supported with

high protein eucaloric feeding. A trial of hypocaloric high protein
feeding is suggested in patients who do not have severe renal or
hepatic dysfunction (Weak). Hypocaloric feeding may be started
with 50-70% of estimated energy requirements or <14 kcal/kg
actual weight. High protein feeding may be started with 1.2 g/kg
of actual weight or 2-2.5g/kg ideal body weight, with adjustment
of goal protein intake by the results of nitrogen balance studies.
{

Evidence grade: low

y 3b. Hypocaloric low protein feedings are associated with

unfavorable outcomes. Clinical vigilance for adequate protein

provision is suggested in patients who do not have severe renal or
hepatic dysfunction (weak).
{

Evidence grade: low

Current Literature
y One small (n=40) observational study examined

hypocaloric, high protein diets vs eucaloric, high

protein diets in critically ill patients with obesity.8
Decreased length of stay in the ICU
Decreased days on antibiotic therapy
Trend towards decreased days on the mechanical ventilator

{
{

y Only RCT (n=30) that examined clinical

outcomes.9

Parenteral nutrition: hypocaloric high protein vs. eucaloric

high protein/control group.
No significant difference in mortality or length of stay
between both groups

{
{

Current Literature
y Positive clinical outcomes noted when surgical patients with

obesity received hypocaloric, high protein parenteral

nutrition.13, 14
{

2 observational case series

One case series (n=23) suggests that parenteral nutrition formulas providing
low calories based on adjusted body weight can be given to patients following
the complications of bariatric surgery without adversely affecting nutrition
goals and parenteral nutrition clinical outcomes. 13
Second case series (n=13) suggests that net protein anabolism and clinical
efficacy can be achieved with hypocaloric, high protein feeding in obese
surgical patients.14
| Should be able to mobilize and use abundant fat stores for energy.
| All patients exhibited tissue healings or wounds and abscess cavities and
closure of fistulae.

y Why a hypocaloric, high protein nutrition regimen?14

Achieve net protein anabolism

Avoid complications from overfeeding

Current Literature
y A prospective observational study examined

relationship between amount of energy and protein

provided to clinical outcomes as well as the impact
of preillness BMI on outcomes.10

Indicated a worsened 60-day mortality rate when a

hypocaloric diet was combined with a low protein intake in
patients with Class II obesity (BMI 35-39.9).

Hypothesized that increasing nutrient provision to

minimize protein-energy deficit in an early phase

of critical illness may improve clinical outcomes.

Especially in lean (BMI >25) and obese patients.

Future Research1
y Current Literature

Clinical outcomes for hospitalized patients with obesity are at least

equivalent, if not improved, by the provision of hypocaloric
feeding when adequate protein is given to achieve net protein
anabolism.

y Future Research
{ Large randomized controlled trial
Does hypocaloric, high protein nutrition therapy offer a significant
therapeutic advantage over eucaloric or hypercaloric feeding with
respect to clinical outcomes and avoidance of complications from
overfeeding for hospitalized patients with obesity?
With EN vs. PN.



4. In obese patients who have malabsorptive or restrictive surgical procedures
for weight loss, What micronutrients should be evaluated?1

y Patients who have undergone sleeve gastrectomy, gastric

bypass, or biolopancreatic diversion +/- duodenal switch

have increased risk of nutritional deficiency. In acutely ill
hospitalized patients with history of these procedures,
evaluation for evidence of depletion of iron, copper, zinc,
selenium, thiamine, folate, and vitamin B12, and D is
suggested as well as repletion of deficiency states (Weak)
{ Evidence grade: low

Micronutrient Deficiency1
y May be a comorbidity of severe obesity
{ Seems to increase in prevalence as the degree of obesity
increases in patients who have had no prior bariatric surgery.
y Documented for iron, selenium, vitamins A, C, D, B6,

B12. and folic acid, alpha and beta carotene. Beta

cryptozanthin, lutein/zeaxanthin, lycopene and total
carotenoids.

Bariatric Surgical Procedures1

y Procedures that change the capacity of the stomach
{

Facilitate weight reduction by restriction.

Increase satiety
Reduce caloric intake
Adjustable gastric band, sleeve gastrectomy

y Procedures that shorten small bowel absorptive capacity.

{

Malabsorption of protein, energy and micronutrients to varying

degrees.
Depending on construction of anatomy
Biliopancreatic diversion

Roux-en-Y gastric bypass (RYGB) and Biolopancreatic

diversion (BPD) +/- duodenal switch (DS) combine the

two above mechanisms.

Current Research1
y Twenty-one observational studies and 2 RCTS have

investigated a variety of micronutrients in pts who have

had bariatric surgery
{
{

Including: RYGB, sleeve gastrectomy, BPD+/- DS, and adjustable

gastric band procedures.
Mostly with short duration of follow-up

y Documented increased risk of deficiency of iron, copper,

zinc, selenium, thiamine, folate, and vitamins B12 and D

compared with preoperative populations.
y Longest study duration (7 years) documented no
deficiency state in pts with restrictive procedures but no
malabsorptive component. 11

American Society for Metabolic and Bariatric Surgery and

the Obesity Society Recommendations1
y Daily multivitamin/mineral supplement.
{ 2 daily doses in patients with SG, RYGB, and BPD.
y 3000 IU vitamin D is recommended
{ To achieve serum 25-hydroxyvitamin D levels > 30 ng/mL
y 1200-1500 mg calcium citrate daily

y 2 mg copper, Iron: 45-60 mg from diet and supplements,

Vitamin B12
{

as needed to maintain normal serum levels.

y Evaluation of folic acid, iron and 25-hydroxyvitamin D

should be done annually.

y Copper, zinc, selenium, and thiamine should be monitored
when patients have specific findings that suggest deficiency.

UVA Bariatric Surgery Center10

y Complete multivitamin/mineral supplement

everyday
y Additional calcium, especially if you do not drink
milk.
{

Calcium citrate with vitamin D recommended

y May need to take additional iron if blood count is low

or if you are a woman who is still menstruating.

A.S.P.E.N. Clinical Guidelines: Nutrition Support of

Hospitalized Patients With Obesity
y 1. Clinical outcomes in patients with obesity can be

impacted my many factors.

{
{

Within 48 hours of ICU admission: Nutrition assessment and

development of a nutrition support plan is recommended.
Within 48 hours of admission: All patients should be screened for
nutrition risk.

y 2. Obese patients are more susceptible to the

complications associated with overfeeding.

{

If indirect calorimetry is unavailable, the use of a predictive equation

to approximate REE is an important part of nutrition assessment.
In Ventilated obese patients: The PSU equation most accurately
predicts REE compared to others.
In non-ventilated obese patients: May use the Mifflin-St. Jeor
equation using actual body weight.

A.S.P.E.N. Clinical Guidelines: Nutrition Support of

Hospitalized Patients With Obesity
y 3. Clinical outcomes for hospitalized patients with

obesity are at least equivalent, if not improved, by the

provision of hypocaloric feeding when adequate protein
is given to achieve net protein anabolism.
y 4. Bariatric surgical procedures are likely to exacerbate
or create micronutrient deficiencies.
{

Recommendation:
Daily multiple vitamin/mineral, Vitamin D, Calcium Citrate
Copper, iron and B12 to maintain normal serum levels
Eval of folic acid, iron, and hydroxyvitamin D should be done yearly.
Copper, zinc, selenium, and thiamine should be monitored when
deficiency suspected.

Practice Applications/Role of The RD

y Educate other healthcare professionals about the

importance of timely nutrition assessment and care in

hospitalized patients with obesity.
y Use the A.S.P.E.N Clinical Guidelines: Nutrition Support
of the Hospitalized Adult Patients With Obesity to
supplement, but not replace, professional training and
clinical judgment in your future practice.
{

Most of these guidelines had a low evidence grade, meaning that,

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FRQILGHQFHLQWKHHVWLPDWHDQGLVOLNHO\WRFKDQJHWKHHVWLPDWH
Therefore it is important to keep up with current research while
practicing!

y Be a part of clinical guideline revision for this paper in

2018 -

Role of the RD Continued

y Nutrition support clinicians are likely to care for

obese patients, especially during hospital

admissions.
y No matter where you choose to start your career, you
will likely be caring for obese patients.

Summary/Take Home Messages

y Clinical outcomes in obese patients are impacted by numerous
y

factors that may complicate the MNT/care given to these patients.

The A.S.P.E.N Clinical Guidelines for nutrition support in
hospitalized patients with obesity can be used to supplement your
professional training and clinical judgment while practicing.
Obese patients are especially susceptible to the complications of
overfeeding and therefore, nutrition support should be effectively
monitored to avoid overfeeding in this population.
Clinical outcomes for hospitalized patients with obesity are at least
equivalent, if not improved, by the provision of hypocaloric feeding
when adequate protein is given to achieve net protein anabolism.
Since bariatric surgical procedures are designed to limit an
individuals nutrient intake, those treated with these procedures may
require nutrition care.
Keep up to date with future research on this topic!!

Questions?

References
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