ESPEN Congress Prague 2007 · Nutrition support in obese patient. Claude Pichard. Nutrition...

Nutrition support in obese patient

Claude Pichard

Nutrition implication of obesity and Type II Diabetes

ESPEN Congress Prague 2007

Nutrition Support in Obese Patients

Prague, 2007

C. Pichard, MD, PhD, Head Clinical Nutrition, University Hospital, Geneva, Switzerland

1. Protecting lean body mass

- Sarcopenic vs. active

2. Defining energy needs

- Predicting vs. Measuring energy expenditure

3. Defining protein needs

4. Micronutrients

- Well vs. malnourished

Nutrition in Obese Patients: Learning objectives


- Sarcopenic vs. active obese patients2. Defining energy needs



4. Micronutrients

- Well vs. malnourished obese patients


INDICATIONS and CONTRAINDICATIONS :

About the same as for non-obese patients !

Nutrition SUPPORT in Obese Patients

Body composition measurements during wasting diseasesC. Pichard et al . Curr Op Clin Nutr 1998, 1: 357-61

Water 39.0 kg=55%

Protein 10.5 kg=15%

Fat16.8 kg=24%

Glycogen0.6%

Minerals=5%

Fat-Free Mass (FFM)

Fat Mass (FM)

70 kg

STRUCTURE AVAILABLEENERGY

70 kg kcal

800

Glycogen420 g = 0.6%

Water 39.0 kg=55%

Protein 10.5 kg=15%

Fat16.8 kg=24%

Minerals=5%24’000

120’000

7 kcal/g

60 % (4 kcal/g)

50% (4 kcal/g)

5 11.2 - 16.8

10 15.2 - 20.8

15 19.2 - 24.8

20 23.0 - 29.0

25 26.8 - 33.2______________________________________________

*95% confidence. Hill G.L. J Parent Enteral Nutr 16, 197-218, 1992

Body weight loss (%) Protein loss (%) *(in vivo neutron analysis)

Unvoluntary weight loss during disease is « Autocannibalism »

0%

20%

40%

60%

80%

100%

Normal FFMI& Normal FMI

Low FFMI& Normal FMI

Normal FFMI& High FMI

Low FFMI& High FMI

≥ 11 d

6-10 d

1-5 d

LOS

Prev

alen

ceIncreased length of hospital stay in underweight and

overweight patients at hospital admission:A controlled population study (1707 patients/1707 volunteers)

Kyle UG et al. Clin Nutr. 2005; 24: 133-142

Sarcopenicvs.

Active Obese patients

Fat Mass Lean Body Mass Total Mass

Dual X-ray Absorptiometry (DEXA)

Bioelectrical Impedance Analysis (BIA)

Review of principles & methods.

Clin Nutr 200423: 1226-1243

Utilisation in clinical practice.Clin Nutr 2004

23: 1430-1453

ESPEN GUIDELINESBioelectrical impedance analysis

www.espen.org/education

Absolute• Transcutaneous lesions• De-hydration, hyper-hydration

Possible if longitudinal follow - up:• Cachexia (BMI > 15.9 kg/m2), obesity (< 35 )• Hemodialysis• Body shape abnormalities

ESPEN GUIDELINESBioelectrical impedance analysis

www.espen.org/education


- Sarcopenic vs. active obese patients


- Predicting vs. Measuring energy expenditure3. Defining protein needs

4. Micronutrients



69 yrs, 156 cm, Pneumonia, no chronic diseaseUsual BW : ? (72 kg nine years ago)Estimated : 115-118 kg Measured :104 kg

Predicting EE in Extremely Obese WomenDobratz JR. JPEN 2007, 31: 217-227

N= 14, BMI 49.8 6.2, 49 +- 10 yrs

- EE : indirect calorimetry

- EQUATIONS:

Harris-Benedict (actual BW)

Cunningham

Mifflin-St Jeor

Owen

World Health Organization

Bernstein

Predicting EE in Extremely Obese WomenDobratz JR. JPEN 2007, 31: 217-227

« The Mifflin-St Jeor equation was most accurate »

Harris-Benedict:Women: 665.09 + (9.56 × wt) + (1.84 × ht) - (4.67 × age)

-> 2045 +/- 215 kcal/d

Mifflin-St Jeor :Women: -161 + (9.99 × wt) + (6.25×ht) - (4.92 x age)

-> 2005 +/- 240 kcal/d

0

400

800

1200

1600

Males(n=64)

Females(n=55)

Total(n=119)

Measured RMR compared to estimated RMR

* Significant difference between measured and estimated RMR (p<0.05)

* *

* * * *

RMR

mea

sure

d

Har

ris B

ened

ict

WH

O/F

AO/U

NU

RMR

mea

sure

d

RMR

mea

sure

d

Har

ris B

ened

ict

Har

ris B

ened

ict

WH

O/F

AO/U

NU

WH

O/F

AO/U

NU

Comparison of equations for estimating resting metabolic rate in healthy subject over 70 years of age

Melzer K et al. Clin Nutr 2007, 26: 498 - 5005

RMR (Harris Benedict) RMR (WHO/FAO/UNU )Females (n=55)

Males(n=64)

Females(n=55)

Males(n=64)

Accurate(within 10%RMRm)

75% 70% 62% 66%

Underestimation(<10% RMRm)

20% 19% 5% 9%

Overestimation(>10%RMRm)

5% 11% 33% 25%

RMR estimation accuracy

Agreement between RMRm and RMRe(Bland and Altman)

200018001600140012001000800

(RMR(Harris Benedict) + RMRm)/2

500

250

0

-250

-500

RM

R(H

arris

Ben

edic

t) -R

MR

m femalesmalesSex

+2 SD

Mean

-2 SD

• Large discrepencies exist between EE predicting formula.

• HB formula performs best.

• Develop more accurate formula including body composition markers

Comparison of equations for estimating resting metabolic rate

In healthy subjects over 70 years of age

Melzer K et al. Clin Nutr 2007, 26: 498 - 5005

ENERGY NEEDSESPEN guidelines on enteral nutrition 2006

AMBULANT BEDRIDDEN

30-35 kcal/ kg* /d 20-25 kcal/ kg* /d

« obese : TEE is lower »Kreymann KG et al. Intensive Care. Clin Nutr 2006, 25: 210-23

« obese : adapted to needs »Arends J et al. Non surgical oncology. Clin Nutr 2006, 25: 245-9

« obese : adapted to individual needs »Cano N et al. Acute renal failure. Clin Nutr 2006, 25: 295-310

ENERGY NEEDS in OBESE Patients

« Geneva »

30-35 kcal/ kg* / d

* Ideal body weight

If « ambulant »:IBW + 20% for

increased Fat-free mass

Calorimetry required if « chronic acute » care or sarcopenia





3. Defining protein needs4. Micronutrients



+10

0

-10

-20

-2 0 +2 +4 +6

NitrogenBalance

(mg/kg/d)

Protein Utilization Depends on Energy Availability

Estimated Energy Balance (kcal/kg/d)

Rombeau J.L. In Clinical Nutrition. Enteral & Tube Feeding. 1990

Protein Needs1.2 – 1.5 g / kg* / d

* Ideal body weight

If « active »:IBW + 20% for increased Fat-free mass

+ compensate in case of severe losses






4. Micronutrients



Why is malnutrition underrecognized ?

Malnutrition

• Financial• Social• « Practical »• Medical….

(Bariatric surgery)

« Obesity does not protect you frommicronutrients deficiencies »

Conclusion

PROACTIVE NUTRITION

« to prevent adverse effectsrelated to poor nutritional status

among high - risk populations »

August DA. JPEN 1996, 20: 394-400

1. Feeding obese patients : same indications & contra-indications

than in non-obese

2. Protecting lean body mass : prevent loss -> be proactive !

3. Defining energy needs : HB or 30-35 kcal /kg (IBW)/ d

Calorimetry required if « chronic acute » care or sarcopenia

4. Defining protein needs: 1.2-1.5 g /kg (IBW)/ d

5. Detecting micronutrients deficits: energy excess = balanced

intakes


5

10

15

20

25

30

35

40

45

50

15-24 25-34 35-44 45-54 55-64 65-74 75-84 >85

Women

Age (years)

95th90th

75th

50th

25th10th5th

Percentiles of Fat Mass in 5225 VolunteersKyle U. et al. Nutrition 2001, 17:534-541

Women

KgKG

8070605040302010030

34

38

42

46

50

54

hommefemme

DEPENSE ENERGETIQUE

ans

kcal

/ m2/

heu

re

Fleisch A. Helv Med Acta 1951;1:23-44

Energy requirements alter with advancing age due to1:

• reduction in the intensity and frequency of physical activity• loss of fat-free mass• decline in Na+-K+- ATPase activity• decrease in muscle protein turnover, and • alteration in mitochondrial membrane proton permeability

1 Wilson MM, Morley JE. Invited review: aging and energy balance. J Appl Physiol 2003;95:1728-36.

Accurate estimation of individual energy requirements is necessaryfor establishing adequate caloric prescriptions.

Agreement between RMRm and RMRe (Bland and Altman)

200018001600140012001000800(RMR(WHO/FAO/UNU) + RMRm)/2

500

250

0

-250

-500

RM

R(W

HO

/FA

O/U

NU

) -R

MR

m femalesmalesSex

+ 2SD

Mean

-2SD

Many equations for estimating RMR!

Harris-Benedict:Men:RMR=66.47+(13.75×wt)+(5.0×ht)-6.75×age)Women:RMR=665.09+(9.56×wt)+(1.84×ht)-(4.67×age)

WHO/FAO/UNU:Men>60yr:RMR=(8.8×wt)+(1128×ht×100)-1071Women>60yr:RMR=(9.2×wt)+(632×ht×100)-302

All equations yield kcal/day, use weight (wt) in kg, and height (ht) in cm and age in years

Two

exam

ples

ESPEN Congress Prague 2007 · Nutrition support in obese patient. Claude Pichard. Nutrition...

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