ESPEN Congress Prague 2007

Transcription

1 ESPEN Congress Prague 2007 Nutrition implication of obesity and Type II Diabetes Nutrition support in obese patient Claude Pichard

2 Nutrition Support in Obese Patients Prague, 2007 C. Pichard, MD, PhD, Head Clinical Nutrition, University Hospital, Geneva, Switzerland

3 Nutrition in Obese Patients: Learning objectives 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

4 Nutrition in Obese Patients: Learning objectives 1. Protecting lean body mass - Sarcopenic vs. active obese patients 2. Defining energy needs - Predicting vs. Measuring energy expenditure 3. Defining protein needs 4. Micronutrients - Well vs. malnourished obese patients

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6 Nutrition SUPPORT in Obese Patients INDICATIONS and CONTRAINDICATIONS : About the same as for non-obese patients!

7 Body composition measurements during wasting diseases C. Pichard et al. Curr Op Clin Nutr 1998, 1: kg Minerals=5% Glycogen 0.6% Water 39.0 kg=55% Protein 10.5 kg=15% Fat 16.8 kg=24% Fat-Free Mass (FFM) Fat Mass (FM)

8 STRUCTURE AVAILABLE ENERGY 70 kg kcal Minerals=5% Water 39.0 kg=55% 60 % (4 kcal/g) Glycogen 420 g = 0.6% Protein 10.5 kg=15% 50% (4 kcal/g) Fat 16.8 kg=24% 7 kcal/g

9 Body weight loss (%) Protein loss (%) * (in vivo neutron analysis) *95% confidence. Hill G.L. J Parent Enteral Nutr 16, , 1992

10 Unvoluntary weight loss during disease is «Autocannibalism»

11 Increased 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: Prevalence 100% 80% 60% 40% 20% LOS 11 d 6-10 d 0% Normal FFMI & Normal FMI Low FFMI & Normal FMI Normal FFMI & High FMI Low FFMI & High FMI 1-5 d

12 Sarcopenic vs. Active Obese patients

13 Dual X-ray Absorptiometry (DEXA) Fat Mass Lean Body Mass Total Mass

14 Bioelectrical Impedance Analysis (BIA)

15 ESPEN GUIDELINES Bioelectrical impedance analysis Review of principles & methods. Clin Nutr : Utilisation in clinical practice. Clin Nutr :

16 ESPEN GUIDELINES Bioelectrical impedance analysis Absolute Transcutaneous lesions De-hydration, hyper-hydration Possible if longitudinal follow - up: Cachexia (BMI > 15.9 kg/m 2 ), obesity (< 35 ) Hemodialysis Body shape abnormalities

17 Nutrition in Obese Patients: Learning objectives 1. Protecting lean body mass - Sarcopenic vs. active obese patients 2. Defining energy needs - Predicting vs. Measuring energy expenditure 3. Defining protein needs 4. Micronutrients - Well vs. malnourished obese patients

18 69 yrs, 156 cm, Pneumonia, no chronic disease Usual BW :? (72 kg nine years ago) Estimated : kg Measured :104 kg

19 Predicting EE in Extremely Obese Women Dobratz JR. JPEN 2007, 31: N= 14, BMI , yrs - EE : indirect calorimetry - EQUATIONS: Harris-Benedict (actual BW) Cunningham Mifflin-St Jeor Owen World Health Organization Bernstein

20 Predicting EE in Extremely Obese Women Dobratz JR. JPEN 2007, 31: «The Mifflin-St Jeor equation was most accurate» Harris-Benedict: Women: (9.56 wt) + (1.84 ht) - (4.67 age) -> /- 215 kcal/d Mifflin-St Jeor : Women: (9.99 wt) + (6.25 ht) - (4.92 x age) -> /- 240 kcal/d

21 Comparison of equations for estimating resting metabolic rate in healthy subject over 70 years of age Melzer K et al. Clin Nutr 2007, 26: Measured RMR compared to estimated RMR RMR measured * Harris Benedict * WHO/FAO/UNU Males (n=64) RMR measured * Harris Benedict Females (n=55) * * WHO/FAO/UNU RMR measured Harris Benedict * WHO/FAO/UNU Total (n=119) * Significant difference between measured and estimated RMR (p<0.05)

22 RMR estimation accuracy RMR (Harris Benedict) RMR (WHO/FAO/UNU ) Accurate (within 10%RMRm) Underestimation (<10% RMRm) Overestimation (>10%RMRm) Females Males Females Males (n=55) (n=64) (n=55) (n=64) 75% 70% 62% 66% 20% 19% 5% 9% 5% 11% 33% 25%

23 Agreement between RMRm and RMRe (Bland and Altman) RMR(Harris Benedict) - RMRm SD Mean -2 SD Sex males females (RMR(Harris Benedict) + RMRm)/2 2000

24 Comparison of equations for estimating resting metabolic rate In healthy subjects over 70 years of age Melzer K et al. Clin Nutr 2007, 26: Large discrepencies exist between EE predicting formula. HB formula performs best. Develop more accurate formula including body composition markers

25 ENERGY NEEDS ESPEN guidelines on enteral nutrition 2006 AMBULANT BEDRIDDEN kcal/ kg* /d kcal/ kg* /d «obese : TEE is lower» Kreymann KG et al. Intensive Care. Clin Nutr 2006, 25: «obese : adapted to needs» Arends J et al. Non surgical oncology. Clin Nutr 2006, 25: «obese : adapted to individual needs» Cano N et al. Acute renal failure. Clin Nutr 2006, 25:

26 If «ambulant»: IBW + 20% for increased Fat-free mass ENERGY NEEDS in OBESE Patients «Geneva» kcal/ kg* / d * Ideal body weight

27 Calorimetry required if «chronic acute» care or sarcopenia

28 Nutrition in Obese Patients: Learning objectives 1. Protecting lean body mass - Sarcopenic vs. active obese patients 2. Defining energy needs - Predicting vs. Measuring energy expenditure 3. Defining protein needs 4. Micronutrients - Well vs. malnourished obese patients

29 Protein Utilization Depends on Energy Availability +10 Nitrogen Balance (mg/kg/d) Estimated Energy Balance (kcal/kg/d) Rombeau J.L. In Clinical Nutrition. Enteral & Tube Feeding. 1990

30 Protein Needs g / kg* / d * Ideal body weight If «active»: IBW + 20% for increased Fat-free mass + compensate in case of severe losses

31 Nutrition in Obese Patients: Learning objectives 1. Protecting lean body mass - Sarcopenic vs. active obese patients 2. Defining energy needs - Predicting vs. Measuring energy expenditure 3. Defining protein needs 4. Micronutrients - Well vs. malnourished obese patients

32 Why is malnutrition underrecognized?

33 Malnutrition «Obesity does not protect you from micronutrients deficiencies» Financial Social «Practical» Medical. (Bariatric surgery)

34 Conclusion

35 PROACTIVE NUTRITION «to prevent adverse effects related to poor nutritional status among high - risk populations» August DA. JPEN 1996, 20:

36 Nutrition in Obese Patients: Learning objectives 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 kcal /kg (IBW)/ d Calorimetry required if «chronic acute» care or sarcopenia 4. Defining protein needs: g /kg (IBW)/ d 5. Detecting micronutrients deficits: energy excess = balanced intakes

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39 Percentiles of Fat Mass in 5225 Volunteers Kyle U. et al. Nutrition 2001, 17: Women KG Kg th 90th 75th 50th 25th 10th 5th >85 Age (years)

40 54 DEPENSE ENERGETIQUE kcal/ m2/ heure homme femme Fleisch A. Helv Med Acta 1951;1: ans

41 Energy requirements alter with advancing age due to 1 : 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 Accurate estimation of individual energy requirements is necessary for establishing adequate caloric prescriptions. 1 Wilson MM, Morley JE. Invited review: aging and energy balance. J Appl Physiol 2003;95:

42 Agreement between RMRm and RMRe (Bland and Altman) RMR(WHO/FAO/UNU) - RMRm SD Mean -2SD Sex males females (RMR(WHO/FAO/UNU) + RMRm)/2 2000

43 Many equations for estimating RMR! Two examples Harris-Benedict: Men: RMR=66.47+(13.75 wt)+(5.0 ht)-6.75 age) Women: RMR= (9.56 wt)+(1.84 ht)-(4.67 age) WHO/FAO/UNU: Men>60yr: RMR=(8.8 wt)+(1128 ht 100)-1071 Women>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