Malnutri)on  and    Body  Composi)on  Issues  

Lecture  1:    Surgical  Nutri0on  Course  Level  3  

 

Body  Compartments  

25% of BCM

75% of BCM

Demling,  R.,  ePlasty.  2009;9:65-‐94.  

Lean Body Mass

!   ADL  (ac0vi0es  of  daily  living)  

!   Physical  strength  

!   Organ  func0on  

!   Wound  healing  

!   Immune  func0on  

Lean  Body  Mass  §  Cell:

§  Membrane and cytoplasmic enzymes and transporters

§  Structural and functional components§  Neural and endocrine

communication/ control of all metabolism and function§  Mediated through protein based

substrates§  Immune system:

§  All cellular and non-cellular defenses: receptors and effectors (=cytokines and interleukins)

§  Heart and cardiovascular system:§  Muscles for contraction§  Sphincters and mechanisms for flow

control

§  Blood§  Transport system/Complement system§  Acid base balance

§  Skeletal muscles§  Contraction and and main protein pool§  Metabolic Amino Acids

§  Alanine§  Glutamine§  Cysteine§  Arginine

§  Pulmonary system§  Gas exchange§  Immune defense

§  Gastrointestinal tract:§  Digestion and absorption§  Membrane and inter-organ immune

defense

§  Liver: all metabolic / detox functions§  Renal System

§  Membrane mechanics§  Acid base balance Harper  Biochem  

Ganong  Physio  Guyton  Physio  

Muscle  and  fat  mass,  all  ages  

•  Catecholamines  •  Glucagon  •  Thyroid  hormones  •  Cor)sol  

Muscle  biopsy  in  cri0cal  illness  

!   Healthy  muscle  is  seen  on  day  1  (A,  C)  with  necrosis  and  a  cellular  infiltrate  on  day  7  (B,  D).    

!   This  infiltrate  was  CD68  posi0ve  on  immunostaining,  indica0ng  macrophage  origin  (red).  

Puthucheary  ZA,  et  al,  JAMA.  2013  Oct  16;310(15):1591-‐600.  

A   B  

C   D  

Inac0vity,  hospitaliza0on  on  LBM  

Sarcopenia  and  morbidity  

COMPLICATIONS  SARCOPENIA  

Sarcopenia:  Vandewoude  M.  Abbo]  Symposium,  ESPEN  2011.  Goteborg,  Sweden.  

Cancer  Cachexia  

Levels  of  Cachexia  

Impaired  glucose  tolerance  

Body  compartments  in    health  and  disease  

WATER  (60%)  

FAT  (25%)  

PROTEIN  (14%)  

WATER  (72%)  

FAT  (15%)  

PROTEIN  (12%)  

WATER  (70%)  

FAT  (23%)  

PROTEIN  (6%)  

CARBO  +  OTHER  (1%)  

NORMAL   STARVATION   CRITICAL  CARE  

WATER  (55%)  

FAT  (30%)  

PROTEIN  (14%)  

OBESE  

Lean  body  mass  and  fat  mass  

WATER  (60%)  

FAT  (25%)  

PROTEIN  (14%)  

WATER  (72%)  

FAT  (15%)  

PROTEIN  (12%)  

WATER  (70%)  

FAT  (23%)  

PROTEIN  (6%)  

CARBO  +  OTHER  (1%)  

NORMAL   STARVATION   CRITICAL  CARE  

WATER  (55%)  

FAT  (30%)  

PROTEIN  (14%)  

OBESE  

↓  LBM  

↑  FAT  MASS  

FLUID  STATUS  

Malnutri0on  and  wound  healing  

Demling  RH.  Eplasty.  Nutri0on,  anabolism,  and  the  wound  healing  process:  an  overview.  Eplasty  2009;9:e9.  Epub  2009  Feb  3.  

Lean  body  mass  loss  and  mortality  

>  60%  Mortality  

Lean  body  mass  loss  and  mortality  Loss  of    Total  LBM  

Complica)ons   Associated    Mortality  

10%   Decreased  immunity  Increased  infec0ons  

10%  

20%   Decrease  in  healing,  increase  In  weakness,  infec0on  

30%  

30%   Too  weak  to  sit,  pressure  ulcers,  Pneumonia,  lack  of  healing  

50%  

40%   Death,  usually  from  pneumonia   100%  

Demling  RH.  Nutri0on,  anabolism,  and  the  wound  healing  process:  an  overview.  Eplasty  2009;9:e9.  

LBM=Lean  Body  Mass  

myofibrils  

sarcoplasm  

Lean  body  mass  loss  and  the  heart  

Lean  body  mass  loss  and  the  heart  

Lean  Body  Mass  Loss  

•  Major  factors:  – Cri0cal  care  state  –  Immobility  – Sarcopenia  – Cachexia  – Poor  intake  

Lean  Body  Mass  Loss  Indicators  •  History:  

–  ↓acute  poor  intake  (>  5%  weight  loss)  –  ↓chronic  poor  intake  (>  5%  weight  loss)  

•  BMI  <  18.5  •  Defini)ve:  

–  BIA  –  CT  scans  

•  Elderly:  have    –  Sarcopenia  –  Sarcopenic  obesity  

•  Cancer:  have  –  Pre-‐cachexia  –  Cachexia  

Lean  Body  Mass/protein  loss  is  severe/worst  in:  1.   Acute:  Cri)cal  care  pa)ents  2.   Long  term:  

1.   Severe  and  chronic  poor  intake  

2.   cachexia  

h]p://www.dpsys120991.com/LL005_Tolen0no_et_al.pdf  

Malnutri0on  detec0on  tools  Nutri)on  screening   Nutri)onal  assessment  

Valida0on  •  Nutri0on  screening  tool  

–  Validated  by  ESPEN  (European  Society  of  Parenteral  and  Enteral  Nutri0on)  and  WHO  (for  the  BMI)  

–  BMI  criteria  locally  validated  by  Mirasol  and  Llido;  Available  at:  h]p://www.dpsys120991.com/POJ_0005.html)  

•  Nutri0on  assessment  tool  –  Validated  by  Lacuesta  et  al.;  available  at:  (

h]p://www.dpsys120991.com/POJ_0002.html)  –  Validated  by  Villaraza  in  thesis  “Valida0on  of  a  Modified  SGA  tool  for  

nutri0on  assessment  in  two  DOH  retained  hospitals  in  the  Philippines”,  PWU,  2013.  

Valida0on  

Mirasol  R  and  Llido  LO.  Comparison  of  Body  Mass  Index  based  nutri0onal  status  using  WHO  criteria  versus  “Asian”  criteria:  report  from  the  Philippines.  PhilSPEN  Online  Journal  of  Parenteral  

and  Enteral  Nutriiton;  Ar0cle  1|  POJ_0005.html)  Issue  January  2010  -‐  January  2012:  1-‐8.  

Valida0on  

Malnutri0on  and  surgical  outcomes  

 Ocampo  R  B,  Kadatuan  Y,  Torillo  MR,    Camarse  CM.  Predic0ng  post-‐opera0ve  complica0ons  based  on  surgical  nutri0onal  risk  level  using  the  SNRAF  in  colon  cancer  pa0ents  -‐  a  Chinese  General  Hospital  &  Medical  Center  

experience.  Phil  J  Surg  Special0es  2007.  Available  at:  h]p://www.dpsys120991.com/POJ_0012.html    

Malnutri0on  and  surgical  outcomes  

Surgical  pa)ents  •  9%  of  moderately  

malnourished  pa0ents  →  major  complica0ons  

•  42%  of  severely  malnourished  pa0ents  →  major  complica0ons  

•  Severely  malnourished  pa)ents  are  four  )mes  more  likely  to  suffer  postopera)ve  complica)ons  than  well-‐nourished  pa)ents  

Detsky  et  al.  JAMA  1994    Detsky  et  al.  JPEN  1987  

Measurement  of  Lean  Body  Mass  

•  Nutri0onal  assessment  – History  of  weight  loss  

•  Bioelectric  Impedance  Analysis  •  CT  Scan  •  DEXA  

Take  home  points  •  Body  composi0on  analysis  gives  informa0on  on  lean  body  mass  and  energy  reserves  

•  Malnutri0on  is  associated  with  loss  of  lean  body  mass  and  energy  reserves  

•  Lean  body  mass  loss  is  associated  with  poor  outcomes  

•  There  is  a  need  to  iden0fy  malnutri0on  in  surgical  pa0ents  to  address/improve  outcomes  

•  Nutri0on  screening  and  assessment  iden0fies  body  composi0on  status  of  surgical  pa0ents  

THANK  YOU