ESPEN Congress Copenhagen 2016

Transcription

1 ESPEN Congress Copenhagen 2016 THE DIVERSITY OF OBESITY MALNUTRITION IN THE OBESE R. Barazzoni (IT)

2 Malnutrition in the obese patient Rocco Barazzoni Dept of Medical, Surgical and Health Sciences University of Trieste - Italy

3 Learning Objectives Malnutrition in the obese - Definition Nutritional risk in the obese Nutritional support in the obese - Special needs and strategies?

4 OBESITY PREVALENCE (10-30%)!

5 OBESITY PREVALENCE (10-30%)! ACUTE DISEASE CHRONIC DISEASE ICU SURGERY OBESE PATIENTS NUTRITIONAL PROBLEMS CKD CHF CANCER AGING

6 ESPEN Obesity Special Interest Group

7 Malnutrition in the obese - Definition Nutritional risk in the obese Nutritional support in the obese - Special needs and strategies?

8 Chronic Disease A Nutritional Journey? EARLY NUTRITIONAL RISK LATE

9 OBESE (BMI>30) AND MALNOURISHED?

10 OBESE (BMI>30) AND MALNOURISHED? v ENERGY STORES (FAT)

11 ASPEN/AND consensus statement Because no single parameter is definitive for adult malnutrition, the identification of 2 or more of the following 6 characteristics is recommended for diagnosis: Insufficient energy intake Weight loss Loss of muscle mass Loss of subcutaneous fat Localized or generalized fluid accumulation that may sometimes mask weight loss Diminished functional status as measured by handgrip strength White et al JPEN 2012;36:275-83

12 International Classification of Disease (ICD) BMI 18.5 kg/m 2 Severe energy store depletion

13 Diagnostic criteria for malnutrition Step 1. Risk screening by a validated instrument, e.g. NRS-2002, MUST, MNA(-SF), SNAQ,... i.e. BMI, Weight loss, Reduced food intake, Disease severity Step 2. Diagnosis BMI <18.5 kg/m 2 or Weight loss >10% (indefinite time)/>5% last 3 mo combined with either BMI <20 (<70 y)/<22 (>70 y) or FFMI <15 and 17 kg/m 2 in women and men, respect. Cederholm et al. Clin Nutr 2015;34:

14 OBESITY GLOBAL Malnutrition Definition and Diagnostic Criteria

15 OBESE (BMI>30) AND MALNOURISHED? v ENERGY STORES (FAT) -PROTEIN STORES (Lean MUSCLE) -MICRONUTRIENTS

16 OBESITY a PERFECT METABOLIC STORM OX STRESS INFLAMMATION MASS FUNCTION INSULIN RESISTANCE

17 OBESITY + a PERFECT METABOLIC STORM AGING CHRONIC DISEASE CRITICAL ILLNESS OX STRESS INFLAMMATION MASS FUNCTION INSULIN RESISTANCE

18 OBESITY a PERFECT METABOLIC STORM SARCOPENIC OBESITY MASS FUNCTION

19 Beyond BMI BODY COMPOSITION Low Lean Mass and Lean Mass loss predict mortality in OBESE CANCER patients Prado et al, Lancet Oncol 2008 Prado et al, Am J Clin Nutr 2013

20 Reduced independence in ELDERLY sarcopenic obese patients Baumgartner et al, Ob Res 2004

21 OBESITY a PERFECT METABOLIC STORM SARCOPENIC OBESITY OUTCOME +

22 Diagnostic criteria for malnutrition Step 1. Risk screening by a validated instrument, e.g. NRS-2002, MUST, MNA(-SF), SNAQ,... i.e. BMI, Weight loss, Reduced food intake, Disease severity Step 2. Diagnosis BMI <18.5 kg/m 2 or Weight loss >10% (indefinite time)/>5% last 3 mo combined with either BMI <20 (<70 y)/<22 (>70 y) or FFMI <15 and 17 kg/m 2 in women and men, respect. Cederholm et al. Clin Nutr 2015;34:

23 Measurement of MUSCLE MASS - Bioimpedence Analysis - CT Scan - DEXA OPEN ISSUES -Reliability -Availability -Standardization -Invasiveness

24 Measurement of MUSCLE MASS - Bioimpedence Analysis - CT Scan - DEXA OPEN ISSUES - Cut-OFFS

25 Diagnostic criteria for SARCOPENIC OBESITY? Step 1. Risk screening by a validated instrument, e.g. NRS-2002, MUST, MNA(-SF), SNAQ,... i.e. BMI, Weight loss, Reduced food intake, Disease severity Step 2. Diagnosis BMI <18.5 kg/m 2 or Weight loss >10% (indefinite time)/>5% last 3 mo combined with either BMI <20 (<70 y)/<22 (>70 y) or FFMI <15 and 17 kg/m 2 in women and men, respect.

26 Malnutrition in the obese - Definition Nutritional risk in the obese Nutritional support in the obese - Special needs and strategies?

27 Nutritional treatment Nutritional Risk Screening (NRS)

28 Nutritional treatment

29 Nutritional support COMMONLY indicated and administered in OBESE patients

30 Malnutrition in the obese - Definition Nutritional risk in the obese Nutritional support in the obese - Special needs and strategies?

31 OBESITY-ASSOCIATED or OBESITY-ENHANCED ISSUES - MUSCLE LOSS MORBIDITY SURVIVAL

32 OBESITY-ASSOCIATED or OBESITY-ENHANCED ISSUES - HYPERGLYCEMIA - HYPERLIPIDEMIA SURVIVAL (ACUTE) COMPLICATIONS (CHRONIC)

33 QUALITY CALORIE GLUCOSE - FAT PROTEIN NUTRITION

34 GUIDELINES: ICU - ASPEN NUTRITIONAL SUPPORT PROTEIN: High-Protein BMI < 40: 2 g/kg IBW BMI > 40: 2.5 g/kg IBW McClave et al, JPEN 2016

35 GUIDELINES: ICU - ASPEN NUTRITIONAL SUPPORT CALORIE - DO NOT OVERFEED! - PROVIDE ADEQUATE CALORIES - PREVENT METABOLIC COMPLICATIONS PERMISSIVE UNDERFEEDING (65-70%) BMI < 50: kcal/kg actual BW BMI > 50: kcal/kg IBW McClave et al, JPEN 2016

36 PERMISSIVE UNDERFEEDING SHORT-TERM GOAL: - MINIMIZING METABOLIC COMPLICATIONS - NOT a WEIGHT-LOSING STRATEGY!! Metabolic Syndrome Abdominal Obesity Hyperglycemia Hypertension Dyslipidemia Triglycerides HDL-Col

37 EVIDENCE?

38 ASSESSMENT OBESITY-associated COMPLICATIONS - CENTRAL ADIPOSITY - SEVERE OBESITY (BMI>40) - METABOLIC SYNDROME - INFLAMMATION HIGHER RISK NUTRITIONAL METABOLIC

39 DOSE - BODY WEIGHT Actual Overestimation Ideal Difficult - APPROXIMATION - ENERGY EXPENDITURE GOLD STANDARD - Indirect Calorimetry SURROGATE Equations

40 CHRONIC DISEASE? CALORIE GLUCOSE - FAT PROTEIN NUTRITION

41 CHRONIC DISEASE Intervention for MUSCLE maintenance PROTEIN Wycherley et al, Am J Clin Nutr 2012

42 CHRONIC KIDNEY DISEASE HEMODIALYSIS PERITONEAL DIALYSIS ESPEN GLs: 1,2-1,4 g/kg BW Cano et al, Clin Nutr 2009

43 AGING 1 1,2 g/kg BW Deutz et al, Clin Nutr 2014

44 CHRONIC DISEASE? PERMISSIVE UNDERFEEDING?

45 Average MUSCLE LOSS 20-25% of TOTAL LOST WEIGHT

46 CHRONIC DISEASE? IF WEIGHT LOSS INDICATED: -Treat metabolic complications -Preserve MUSCLE MASS ( protein, exercise)

47 - Nutritional support in obese patients should prioritize MUSCLE MASS maintenance. - Permissive underfeeding could contribute to prevent-minimize potential metabolic abnormalities - More studies are needed to define optimal caloric intake in different clinical conditions

48 MICRONUTRIENT ABNORMALITIES

49 Intake Requirements MICRONUTRIENT Balance

50 MORBID OBESITY Intake Requirements MICRONUTRIENT Balance

51 Micronutrient deficiencies in morbidly obese patients Damms-Machado et al, Nutr J 2012 Van der Beek et al, Ob Surg 2015

52 MORBID OBESITY BARIATRIC SURGERY -Iron -Folates -Calcium -Vitamin D -Vit B (1,12) -[Cu-Zn-Mg-Se]

53 MORBID OBESITY BARIATRIC SURGERY -Deficiencies -Supplementation

54 Successful treatment by supplementation Van der Beek et al, Ob Surg 2015

55 Conclusions - Obese patients are prone to additional nutritional disorders including sarcopenia, micronutrient abnormalities and potentially malnutrition/undernutrition (according to definition!) - Increasing awareness, specific diagnostic thresholds, tools and cut-offs as well as treatment strategies are necessary to improve patient identification and consequently treatment and outcome

56 Conclusions - Obese patients are prone to additional nutritional disorders including sarcopenia, micronutrient abnormalities and potentially malnutrition/undernutrition (according to definition!) Call for: MORE STUDIES - Increasing awareness, specific diagnostic thresholds, MORE EVIDENCE tools and cut-offs as well as treatment strategies are necessary to improve patient GUIDELINES identification and consequently treatment and outcome

57 Thank you for your attention