Speaker Disclaimer Protein: A New Perspective Opinions and positions expressed by the speaker are solely those of the speaker and do not necessarily reflect the views, opinions or positions of Nutricia North America or any employee thereof. Speaker: Mara Lee Beebe, MS, RD, LD, CNSC Developed by: Ainsley Malone, MS, RD, LD, CNSC, FAND, FASPEN Objectives Outline the essential role protein plays in nutrition intervention Describe current evidence supporting protein provision in specific populations The older adult Critically ill patients The obese patient Outline current guideline recommendations for protein requirements Define practical strategies for achieving protein requirements via case application Protein Essential Facts Essential components of all living organisms Most important macronutrient Amino acids building blocks and intermediates Essential, non-essential, conditionally essential Peptides Di and tri peptides Complex proteins Structure variation impacts function
Protein Functions Protein Digestion and Absorption Protein Requirements RDA: 0.8 g/kg BW/d for adults «Minimal amount» Acceptable Macronutrient Distribution Range (AMDR) 10-35% total calories Research supports some may benefit from protein intakes greater than the RDA Athletes / highly active adults Older adults Protein Requirements The RDA minimal amount is based on metabolic equilibrium concept Nitrogen balance study method utilized 0.65 g/kg/d body weight for healthy adult 2 standard deviations to account for individual variation Requirement reflects safe requirement to avoid a deficiency leading to loss of LBM
Selected Protein Requirements Protein Requirements in Specific Populations Older Adult Malone AM, Russell MK. Nutrient Requirements. Pocket Guide to Nutrition Assessment Academy of Nutrition and Dietetics 2015, 3rd Ed. Obesity Critical Illness Age Related Causes of Protein Deficits The Older Adult JAMDA 2013;14:542-559
Re-examination of Protein Requirements in Older Adults Negative nitrogen balance demonstrated with lower protein intake in older adults1 Study compared 0.8 to 1.62 g/kg/d protein Negative N balance of -4.6 ±3.4 vs positive 3.6 ±1 Three weeks of consuming 0.8 g/kg/d resulted in loss of lean body mass2 Diet controlled study of 10 ambulatory men/women (55 77 yrs) Decreased urinary nitrogen Decreased thigh muscle area It is fundamental, as the basis for assessing its adequate intake, to move from a focus on meeting the dietary protein requirement when it is defined by body nitrogen balance studies to defining optimal intakes for health and reduction of chronic disease. 1Am J Clin Nutr 1994;60:501-09; 2J Gerontol A Biol Sci Med Sc 2001;56:M373-80 Nutrients 2015, 7, 6874-6899; doi:10.3390/nu7085311 Recommendations for Protein in the Older Adult Critical Illness ESCEO: European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis ESPEN: The European Society for Clinical Nutrition and Metabolism PROT-AGE: International study group to review dietary protein needs with aging Clin Geriatr Med 2015;31:327-338
Critical Illness Protein Catabolism Nitrogen Excretion http://clinicalgate.com/nutritional-support-for-the-pediatric-patient/ JPEN1979;3:452-456 Nitrogen Balance in Critical Illness Prospective randomized trial in 50 critically ill patients - CRRT Control group = 2 g/kg/day for 6d Treatment group = 1.5 g to 2.5 g for 6 d stepwise intake Nitrogen balance on days 2, 4 and 6 Via urine and/or dialysate analysis Neutral and/or + nitrogen balance more likely with > 2 g/kg/d (p=0.0001) Nitrogen balance associated with positive clinical outcomes Nutrition 2003:19:909-916 Protein Intake and Outcomes Observational Studies
Protein Intake and Outcomes RCT Ferrie, et al 2015 - Results Ferrie S. JPEN 2015; epub 12 month study in Australian medical/surgical ICU (n=119) Randomized to two PN formulas 0.8 g/kg/d or 1.2 g/kg/d Outcomes Primary: hand grip strength at discharge Secondary: fatigue score, nitrogen balance, arm/leg anthropometrics and ultrasound, hospital LOS and mortality Conclusion: A higher amount of amino acids demonstrated improvements in several outcomes and provides support for an increased protein recommendation Ferrie S. JPEN 2015; epub Amino Acid Infusion and Protein Balance Pilot study Liebau F. Crit Care 2015;19:106 Aim: Can supplemental parenteral amino acids (AA) improve protein turnover in critically ill patients? 13 patients received 1 g/kg/d AA over 3 hrs in addition to standard care during 1st week in the ICU AA plasma concentrations increased Protein synthesis and protein balance increased No changes in protein breakdown Guidelines for Protein Intake Supplemental parenteral amino acids can be used in critically ill patients for body protein accretion during the first week of ICU treatment J Parent Ent Nutr 2016;40:159-211; http://www.criticalcarenutrition.com/docs/cpgs%202015/4.2c%202015.pdf Clin Nutr 2009;28:359-479
ASPEN/SCCM Protein Recommendations Obesity Taylor B. CCM 2016:44:390-438; McClave S. JPEN2016;40:159-211 Rationale for Underfeeding with High Protein in Obesity Choban and Dickerson - 2005 Combined data sets from individual studies using a lower calorie, high protein regimen Evaluated morbidly obese (Class III = BMI 40) N = 70 44 provided hypocaloric regimen 26 provided eucaloric regimen Via regression determined higher protein intake is needed 1.9-2.5 g/kg/ibw in critically ill patients Trend toward worsening hyperglycemia in Class III compared to less obese Nutr Clin Pract 2005;20:480
Protein Intake and Nitrogen Balance Protein Requirements Types I,II (BMI 30-40) Protein in Obese Trauma Dickerson 2013 Prospective evaluation in critically ill older trauma patients requiring EN or PN Question: differences in nutrition response and clinical outcomes in older vs younger patients Stratified by age 18-59 yrs (n=41);!60 yrs (n=31) ± 18 Type III (BMI>4 0) Choban, Dickerson (NCP 2005;20:480) Variable! 60 years 18-59 years P value Kcal/kg IBW/day 21±5 18±4 0.002 Protein, g/kg IBW/day 2.1± 0.4 1.9±0.3 0.016 Serum urea nitrogen (SUN) 30±14 20±9 0.001 SUN Max 43±19 28±12 0.001 J Parent Ent Nutr 2013;37:342 Dickerson - 2013 Guidelines What Do They Tell Us? Nitrogen Balance p=.363 (mean) - NS J Parent Ent Nutr 2013;37:342 2.3 ± 0.3 g/kg No significant clinical outcome differences between older and younger groups Those who achieved a positive N Balance more likely to survive A trial of hypocaloric high protein feeding is suggested in patients who do not have severe renal or hepatic dysfunction (Weak and EC) Obesity: High protein feeding may be started with 1.2 g/kg actual weight or 2-2.5 g/kg ideal body weight, with adjustment of goal protein intake by the results of nitrogen balance studies Critical Care: Suggest protein should be provided in a range: BMI 30 40: 2 g/kg/ibw/day BMI > 40: 2.5 g/kg/ibw/day J Parent Ent Nutr 2013;37:714-744; J Parent Ent Nutr 2016;40:159-211
Hypocaloric HighProtein Regimens in Obese Patients -?? s Guidelines What Do They Tell Us? Hypocaloric low protein feedings are associated with unfavorable outcomes. Clinical vigilance for adequate protein provision is suggested A.S.P.E.N. 2013 Clinical Guidelines for the Obese Patient Observational cohort study of ICU patients 2722 patients 333 with Class II or III obesity Average calorie intake 1009 kcals Average protein intake 46 g/day 0.4 g/kg/day (IBW) Mortality higher in the Class II obesity group (0.039) Intens Care Med 2009;35:1728. Putting It All Together How To Achieve High Protein Requirements TPN formulas Requires high amino acid base formulation 15% Lower base AA formulations result in increased fluid intakes Difficulty with standardized (pre-mix) formulas Enteral formulas Improved options with introduction of very high protein EN formulas Protein content = 35% - 37% (87.3-92.5 g/liter) Additional formulas to consider (25% protein)
Protein Modulars - Practicalities Available as powdered or liquid formulations Powdered form requires mixing with 30-60 ml water Liquid forms are typically mixed with 30 ml water Source of protein Whey protein isolate Whey/casein isolate blend Hydrolyzed collagen with added tryptophan Content ranges from 6-15 g/serving 1 ounce liquid or 1 packet powder Practicalities in Achieving Protein Requirements BMI Protein Requirements (75 kg IBW) EN Formula 18% protein EN Formula 25% protein EN Formula 37% protein Per Guideline Energy Recommendations Protein supplement 30-40 150 g/day 55 g 83 g 115 g 35 g 55 g/d 40+ 188 g/day 55 g 83 g 115 g 73 g 133 g/d 50+ 188 g/day 76-87 g 103-117 g 144-164 g 24 g 112 g/d 14 kcals/kg actual weight (200#/90.9kg) 1270 kcals (BMI 30-50) 22-25 kcals/kg IBW (70 /166#/75kg) 1650 1875 kcals (BMI >50) Taylor B. CCM 2016:44:390-438; McClave S. JPEN2016;40:159-211 Meeting Current Protein Guidelines Using a Protein Modular Study aim: examine ASPEN/ESPEN protein critical care guidelines can be met with standard/high protein formulas Without overfeeding calories 1.2-1.5 g protein/kg/d 2-2.5 g protein/kg (IBW)/d 139 patients on full enteral nutrition Achieved protein requirements in 75% of patients Using a modular protein supplement increased achieving requirements to range of 82% to 100% Use of Protocols to Achieve Desired Protein Intakes Pep Up Protocol Critical Care Nutrition Two options for feeding Volume based feeding Trophic feeding Semi-elemental formula at initiation Protein modular supplementation at initiation Prokinetic at initiation All components reviewed daily Taylor S. Clin Nutr 2016;11:e55-e62 http://www.criticalcarenutrition.com/pepup/study-tools
Pep Up Protocol Effectiveness Multicenter quality improvement initiative ICU s using protocol compared with concurrent control group of ICU s Respiratory and sepsis top two admission diagnosis APACHE 11 scores of 21.7 and 24.2 Feed Me Protocol* Feed Early Enteral Diet Adequately for Maximum Effect Volume based feeding approach Implemented as an alternative to traditional rate-based feeding approach Heyland DK. J Parent Ent Nutr 2015;39:698-706 * Taylor B. Nutr Clin Pract 2014;29:639-648 Feed Me Protocol Effectiveness* Case Application Pt BK is a 44 yo male admitted with SBO. Consult for TPN POD# 1 from ex-lap with partial colectomy, end ileostomy, intraperitoneal drain placement, and wound vac due to bowel perforation. Patient Information Ht: 6 0 Wt: 111kg BMI 33 PMH: diverticulitis, partial colectomy ileosigmoid anastomosis and VHR 6 months ago due to colonic obstruction, Roux-en-y gastric bypass 9 years ago, peripheral neuropathy, gout, alcohol abuse. Clinical Information Intubated and sedated NPO since admission (6 days). Medications: protonix, propofol, levophed, vasopressin, NS MIV Pertinent labs: Na 142, K 3.5, Cl 118, CO2 20, BUN 23, creat 1.37, phos 2.3, mg 2.1, ionized calcium 1.12, WBC 14.9, PH 7.314 Protein g/kg/actual weight: 1.1 (0.3) vs 1.3 (0.4) (p=0.36)
Nutrition Assessment Unable to obtain full nutrition history due to vent. Per H&P, symptoms started day of admission. No reported wt loss. No signs of muscle or fat wasting. + Edema but was severely fluid positive at time of assessment. History of alcohol abuse-8 beers/day but recently reduced to a few beers 3-4 days per week per H&P. At risk for malnutrition. Estimated Energy Needs: 1215-1554Kcals/day (11-14kcals/kg actual wt)* 1361Kcals/day (60% of Penn State 03) Estimated protein needs: 162g (2g/kg IBW)* Additional needs: Thiamine/folate for alcohol hx *Per Critical Care Guidelines Hospital Course and Nutrition Intervention Day 1-3 Consult to Nutrition Support Team to start parenteral nutrition (PN). Intervention: Goal PN (including propofol) provided 1450kcals (14kcals/kg actual wt) and 165g pro (2g/kg IBW). Lipids held due to propofol (300kcals/day). Multiple electrolyte abnormalities addressed. Trophic tube feeds (TF) initiated on day 3 by surgery team. Hospital Course and Nutrition Intervention Day 4 Consult to advance tube feeding slowly to goal. Propofol weaned off. Intervention: Very high protein formula increased 10ml every 8 hrs to goal of 60ml/hr with a protein modular 3x per day to provide 1560kcals and 160g pro per day. Wean PN per with TF advancement. Hospital Course and Nutrition Intervention Day 7 Emergently taken to OR for abdominal washout with temporary abdominal closure due to intraabdominal abscess and wound dehiscence. Intervention: TF held and PN resumed previous goal.
Hospital Course and Nutrition Intervention Day 9 Pt returned to the OR on day 9 for complex wound closure. Consult to restart tube feeds post-op. Intervention: TF continued per previous goal (14kcals/kg actual wt and 2g pro/kg IBW). PN wean ordered per protocol. Pt continued to tolerate TF at goal rate while on the ventilator. Nitrogen balance study obtained after 3 days at goal TF. Protein increased to 2.3g/kg IBW due to negative result. Conclusion BK tolerated both parenteral and enteral nutrition without hyperglycemia while on the hypocaloric regimen. A protein modular was required to meet the patient s protein needs while on tube feedings despite using a very high protein enteral formula. BK transition to a skilled nursing facility at discharge on both TF and an oral diet. Conclusion and Take Away Protein is an essential component of nutrition intervention Re-examination of requirements for the older adult Increasing evidence toward improved outcomes with early protein intakes in the critically ill High protein with lower calories of potential benefit in the obese patient Higher protein enteral formulas and/or modular protein supplementation necessary References 1. Wolfe RR, Miller SL. The recommended dietary allowance of protein: A misunderstood concept. JAMA 2008;299:2891-2893. 2. Campbell WW, Crim MC, Dallal GE, et al. Increased protein requirements in elderly people: new data and retrospective reassessments. Am J Clin Nutr 1994;60:501-09. 3. Campbell WW, Trappe TA, Wolfe RR, Evans WJ. The recommended dietary allowance for protein may not be adequate for older people to maintain skeletal muscle. J Gerontol A Biol Sci Med Sci 2001; 56:M373-80. 4. Nowson C, O Connell S. Protein requirements and recommendations for older people: a review. Nutrients 2015;7:6874-6899. 5. Bauer JM, Diekmann R. Protein and older persons. Clin Geriatr Med 2015;31(3):327-338. 6. Long CL, Schaffel BS, Geiger JW, et al. Metabolic response to injury and illness: estimation of energy and protein needs from indirect calorimetry and nitrogen balance. JPEN J Parenter Enteral Nutr 1979;3:452-456. 7. Scheinkestel CD, Kar L, Marshall K, et al. Prospective randomized trial to assess caloric and protein needs of critically Ill, anuric, ventilated patients requiring continuous renal replacement therapy. Nutrition 2003;19:909-916. 8. Weijs PJ, Stapel SN, degroot SD, et al. Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: a prospective observational cohort study. JPEN J Parenter Enteral Nutr 2012;36:60-68. 9. Allingstrup MJ, Esmailzadeh N, Knudsen AW, et al. Provision of protein and energy in relation to measured requirements in intensive care patients Clin Nutr 2012;31:462-468. 10. Nicolo M, Heyland DK, Chittam J, et al. Clinical Outcomes Related to Protein Delivery in a Critically Ill Population: A Multicenter, Multinational Observation Study. JPEN J Parenter Enteral Nutr 2016;40:45-51. 11. Ferrie S, Allman-Farinelli M, Daley M, Smith K. Protein Requirements in the Critically Ill: A Randomized Controlled Trial Using Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2016;40:795-805. 12. Liebau F, Sundstrom M, van Loon LJ, et al. Short-term amino acid infusion improves protein balance in critically ill patients. Crit Care 2015;19:106. 13. Choban PS, Dickerson RN. Morbid obesity and nutrition support: is bigger different? Nutr Clin Pract 2005;20:480-487. 14. Dickerson RN, Medline TL, Smith AC, et al. Hypocaloric, high-protein nutrition therapy in older vs younger critically ill patients with obesity. JPEN J Parenter Enteral Nutr 2013;37:342-351. 15. Choban P, Dickerson R, Malone A, Compher C. A, American Society for Parenteral and Enteral Nutrition Clinical Guideline: Adult Obesity. JPEN J Parent Ent Nutr 2013; 37: 714-744.
References 1. Alberda C, Gramlich L, Jones N, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med 2009;35:1728-1737. 2. Taylor ST, Dumont N, Clemente R, et al. Critical care: Meeting protein requirements without overfeeding energy. Clin Nutr ESPEN 2016;11:e55-e62. 3. Heyland DK, Dhaliwal R, Lemieux M, Wang M, Day AG. Implementing the pep up protocol in critical care units in canada: results of a multicenter, quality improvement study. JPEN J Parenter Enteral Nutr 2015;39:698-706. 4. Taylor B, Brody R, Denmark R, Southard R, Byham-Gray L. Improving enteral delivery through the adoption of the feed early enteral diet adequately for maximum effect (feed me) protocol in a surgical trauma ICU: a quality improvement study. JPEN J Parenter Enteral Nutr 2015;39:698-706. Thank You!!