Critical Care

fEEDIng CRITICAlly Ill obESE PATIEnTS

kaylee Allan bsc (Hons) dietetics, PgCert Applied sports Nutrition specialist dietitian, North bristol NHs Trust

for article references please email: info@network healthgroup.co.uk

Since graduating, kaylee has spent over four years specialising within intensive care and adult burns. She is also part of a small research team on the ICu.

Despite ongoing nutritional research in this area, there is a paucity of high quality research to guide the feeding of obese patients on the intensive care unit (icu). in a nutritionally complex population, this paper will review the available evidence and summarise key points to consider when assessing the nutritional requirements in the critical ill obese.

Obesity remains on the increase; in England, 61.9% of the adult population are overweight or obese.1 The cost to the health service for overweight and obese patients is greater than £6 Billion a year1,2 and contributes to 30,000 excess deaths in the UK.3

The ICU ‘obesity paradox’ has been used to describe this observed phenomenon of improved survival of the obese patients, despite increased lengths of stay,4 the opposite to what many might expect. Audits4 and multicentre observational studies5 evaluating the outcome of obesity in critical illness, found that patients with a BMI of between 30-39 and >40 had a lower mortality when compared to a normal BMI (<25). Theories try to explain why the obesity paradox exists, one suggestion is altered metabolism of the adipose tissue, an increase in Leptin levels and beneficial functions of adipose tissue in response to sepsis.5,4 Despite a large sample size of the studies, the morbidly obese patients (BMI >40) represented only 3.5% of the study population.4 A recent systematic review has also cast doubt over the existence of this paradox.6

Even if the ICU obese paradox exists, complexities arise with the medical and nutritional management of the obese critically ill patients that impact on morbidity. There is a strong link between obesity and insulin resistance and a prevalence of fatty liver and respiratory compromise. The risk of hypothalamic and pituitary dysfunction can result in increasing levels of the stress hormone cortisol. Poor mobility due to the critical illness heightens patient risk of pulmonary embolisms or deep vein thrombosis due to the patient’s hyper-coagulable state . 2, 7 Locally, over the last year, our ICU admitted 1,775 patients; of these, nearly a quarter (23%) were obese (BMI >30) and 4.0% morbidly obese (BMI >40).There is a need to have a consensus amongst our profession to ensure that the nutritional management of the obese patient is appropriate and evidenced based. Establishing a definitive nutritional pathway for obese patients on ICU remains an ongoing issue for dietitians due to complexities with assessing the nutritional need of the patient, alongside prescribing feeding regimens with adequate macro and micronutrients.8

NUTRITIONAl REqUIREmENTs Without the use of indirect calorimetry, predictive equations must be used when assessing nutritional needs of a patient.9 Predictive equations can be inaccurate and lead to over or under estimations of calorie and protein needs.9 The Parenteral and Enteral Nutrition Group (PENG)10 recommends calculating estimated energy requirements (EER) based on disease-related stress for BMI >30, protein/g/kg/d is adjusted to 75% and 65% requirements for obesity and morbid obesity respectively (Table 1). The supporting evidence behind this recommendation is somewhat sparse.

source: adapted from frankenfield 2013 et al with permission.9 IbW: ideal body weight, mAT: metabolically active tissue. Penn state: (equation 1, for all patients irrespective of age).

Frankenfield et al9 evaluated the available predictive equations for 55 mechanically ventilated obese patients with a BMI >45. Predictive equations were compared to measured energy expenditure (MEE) to determine accuracy (Figure 1). The equation with the highest accuracy (±5.0% of measured EE) was the Penn State equation (2011); however, this was accurate in only 51% of the patients, so caution should be taken when using this equation in those with a BMI >45. The IretonJones equation (1992), which was developed specifically to include obese hospitalised patients, had an accuracy of 16% (to ±5.0% of MEE) and fixed kcal equations (25kcal/kg) has an accuracy of 0% to +/-10% if MEE.9

See Figure 1 for the predictive equations. Those recommended are highly inaccurate.9

Choban et al (2013) recommend the Penn State University equation (2009) should be used and the adjusted Penn State calculation used in patients over 60 years old. Recommendations for hypocaloric, high protein feeding suggest using 50-70% estimated energy requirements or 14kcals/ kg actual weight. Protein ranges are increased in the obese group (BMI >30), but supported with low grade evidence, see Table 1.11

Current guidelines offer suggestion to dietitians when calculating nutritional requirements in obese patients.

ASPEN’s D grade recommendations for feeding the obese ICU patients accounts for underfeeding calories, but feeding high protein allows for neutral nitrogen balance and wound healing.11, 12

Calculating protein requirements is just as problematic as estimating calorie requirements in the obese ICU patient. Table 1 gives a variety of protein ranges based on actual or ideal body weight. Obese patients have an increased level of total body fat as well as an increase of lean body mass (LBM) and IBW does not correlate to this change in body habitus. Accurately obtaining LBM is costly and often not feasible at the bedside, so using an equation to calculate LBM has been recommended.15, 16

HYPOCAlORIC Vs PERmIssIVE UNdERfEEdING Where indirect calorimetry and predictive equations accounting for obesity are not available, then clinical guidelines may assist and direct nutritional prescriptions in ICU obese patients. As Table 1 presents, giving a percentage or lower amount of calories to the obese patient (hypocaloric feeding) may be helpful in preventing negative side effects of overfeeding ICU patients, such as hyperglycaemia.7

Determining how much to feed the ICU obese patient will vary depending on clinical condition and individual aim. Within the literature, terminology varies and it is important to distinguish the significant difference of the two

Guidance

American society for Parenteral and Enteral Nutrition AsPEN11,12,13

Parenteral and Enteral Nutrition Group (PENG)10

American College of Chest Physicians (ACCP)14

kreymann et al 201515

Energy

bmI >30-50 60-70% energy requirements or 11-14kcal/kg/actual body weight or bmI >50: 22-25kcal/kg ideal body weight

Protein

bmI >30-40 >2.0g/kg Ideal body weight bmI > 40 >2.5g/kg ideal body weight

bmR - Henry (2005) or in ventilated patients use IretonJones equation (2002) bmI>30 Not stressed: subtract 400-1000kcals. mildly stressed: feed to bmR (calculated using actual body weight) moderate stress: feed to bmI +/_ activity or stress factor severely stressed: add a stress factor OR use 19-21kcal/kg actual body weight bmI >30 75% protein requirement bmI >50 65% protein requirement

21-25kcal/kg/actual body weight do not give recommendations for protein requirements

Use standard body weight (sbW - adapted from lemmens et al, based on bmI 22) x 25kcal 25kg x kg sbW based on lbm (adapted from fernandez) and decide on range of protein required depending on clinical picture

terms: hypocaloric and permissive underfeeding. Hypocaloric feeding suggests low calories (mainly as carbohydrate) whilst maintaining adequate protein. Permissive underfeeding is a conscious decision to underfeed calories alongside protein.7

Hypocaloric feeding (low calorie, less than predicted energy expenditure) with adequate protein provision >1.2g/kg/d Ideal Body Weight (IBW) aims to maintain lean body mass (LBM) whilst simultaneously losing fat mass. Underfeeding calories aims at avoiding the metabolic complications associated with overfeeding in ICU patients, such as hyperglycaemia, increased infections and increased ventilator days.7

A small retrospective study of 40 obese ICU patients receiving enteral nutrition were fed either <20kcals/kg adjusted body weight/d (hypocaloric feeding) or >20kcals/kg adjusted body weight/d (eucaloric feeding). The findings suggested that the hypocaloric group had shorter ICU stay (P <0.03) and reduced number of ventilator days (P <0.09). Both groups were fed equal amounts of protein (2.0g/kg/d IBW).17

There is a lack of quality randomised control trials reviewing nutritional prescriptions for this patient group. However, the American guidelines suggest that hypocaloric, high protein feeding is at least equivalent as permissive underfeeding, if not improved when adequate protein is provided.8

HYPOCAlORIC, HIGH PROTEIN fEEdING Using the hypocaloric high protein feeding strategy to optimise outcomes in the critically ill obese can present practical complications for dietitians prescribing enteral feeding regimes. Using commercial available enteral feeds can be a challenge to meet both requirements for protein and obligatory glucose without overfeeding, especially when also factoring in the delivery of non-nutrient calories such as propofol or IV fluid solutions. Failure to meeting obligatory glucose levels can lead to gluconeogenesis and exacerbate further loss of muscle mass.8

Protein supplements alongside commercially available tube feeds with a lower non-protein energy:nitrogen ratio <1:80) can improve protein intake without overfeeding energy.8 Adjustment of feeding regimens goes beyond that of using a pure

protein supplement. Careful adjustment in feed prescription is essential when accounting for the nonnutritional energy provided in the form of intravenous fluids, sedation preparations and renal replacement solutions. Failure to adjust will lead to excess energy from non-nutritional sources, or displacement and reduction of protein intake. The provision of a protein and carbohydrate mixed supplements can help close the protein gap while meeting obligatory glucose requirement. Micronutrient provision will also need to be considered when making adjustments for macronutrients.8

sUmmARY Despite a suggestion of lower mortality from critical illness, obese critically ill patients present a lot of nutritional challenges to dietitians working on the ICU. We lack definitive answers to guide prescriptions for the ICU obese patient, but emerging evidence suggests that the trend towards hypocaloric feeding alongside adequate protein and glucose provision improves outcomes and prevents substrate intolerance. Estimating energy requirements should include using evidenced based and validated predictive equations, mindful that the accuracy of these equations falls as BMI increases >45.9 Consideration for non-nutrient energy sources, adequate micronutrient provision and the use of protein and carbohydrate supplements help bridge the protein gap to ensure this patient group are adequately fed to optimise outcomes.

kEY POINTs • Use indirect calorimetry or validated predictive equations for the ICU obese patients. • If predictive equations aren’t available, follow international guidelines ensuring adequate protein is provided. • Feeding regimens need to be adjusted to allow for non-nutritional energy from sedation preparations, intravenous fluids and renal replacement solutions. • Consider a protein supplement to improve the protein adequacy, without over-feeding.

Commercially available feeds may not provide enough protein for patients with increased protein requirements. • Pre-admission nutritional status: consider micronutrient deficiencies and adjust depending on clinical conditions.

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kirstine farrer Consultant dietitian, salford Royal NHs foundation Trust

kirstine specialises in intestinal failure on the national unit at Salford Royal. She has extensive clinical experience, specifically in the management of short bowel syndrome and home parenteral nutrition,

MAlnuTRITIon In THE ElDERly: IDEnTIfyIng AnD SIgnPoSTIng wITH THE PAPERwEIgHT ARMbAnD

kirstine is part of a team that is pioneering the PaperWeight Armband - a non-medical, non-intrusive tool that is helping health and social care professionals to identify people at risk of malnutrition and signpost them to information and advice.

The idea stemmed from being part of a 12-month national pilot programme set up by the Malnutrition Taskforce. The vision was to demonstrate an integrated approach to dealing with malnutrition; aligning health and social care and the voluntary sector. Now, thanks to a partnership with Age UK Salford, the PaperWeight Armband is set to be rolled out across the country to help save lives and cut costs associated to treating the condition - with a simple strip of paper.

There has never been a more urgent need for healthcare providers and commissioners to act and address the problem of malnutrition. Needless suffering, neglect and inconsistent standards of dignity are unacceptable. Malnutrition is a major cause and consequence of poor health and older people are particularly vulnerable. It is a condition that frequently goes undiagnosed and untreated, with one in 10 older people suffering from, or at risk of, malnutrition. This equates to around one million older people in the UK and more than one in three are malnourished, or at risk of malnourishment on admission to hospital.

Not only is this intolerable from a health perspective for the quality of life in older people, malnutrition can lead to more hospital admissions and readmissions, longer hospital stays and greater healthcare needs, which means the cost of malnutrition can spiral out of control.

Here in Salford, we have an unashamedly ambitious aim. We wish to ensure that we work in collaboration with health and social care and the voluntary sector to remain committed to ensuring high standards of nutritional care and equal access across the city. The challenge was how to go about this and our journey with the PaperWeight Armband started in 2013, when Salford was chosen as one of six pilot sites to be part of a Malnutrition Prevention Programme for 12 months. We looked at current services, support and prevention tools available and gained views from members of the public and health and social care professionals through a nutrition committee set up by the integrated care programme ‘Salford Together’. It was concluded that we wanted to establish a non-intrusive, non-medical intervention solution that healthcare providers and the voluntary sector would be able to implement quickly and easily into their practice. The PaperWeight Armband was born out of this.

PIlOTING THE PAPERWEIGHT ARmbANd Age UK Salford supported the case for a simple signposting tool, as there was not one currently available to help carers, healthcare or social care professionals in broaching the subject of malnutrition. A public engagement exercise with older adults, who thought it was normal to lose weight in later life, also revealed that some did not want to be weighed.

Age UK Salford went on to pilot the PaperWeight Armband with support

workers using it on home visits. They were able to measure the upper arm of a service user with the simple strip of paper and, if it was able to slide up and down easily, then there was a high risk of malnutrition, as it was likely that their BMI was less the 20kg/m². The charity Age UK was then able to provide further information, advice and support and the results were really positive, with service users gaining weight, making improvements to their diet, and enjoying cooking and eating again.

When the national Malnutrition Prevention Programme ended in March 2015, it was agreed by the nutrition committee that there was a strong commitment to continue this work to roll-out the PaperWeight Armband and Age UK Salford have partnered with us to make this happen. The PaperWeight Armband was launched at Food Matters Live 2015 and now, alongside this signposting tool, there is a supporting handbook, nutrition booklet and e-learning resources on malnutrition and dysphagia.

AdVICE ANd GUIdANCE The aim of the PaperWeight Armband package is to identify the risk of malnutrition and in turn help to reduce unscheduled admissions to the acute hospital of those identified with malnutrition in the population, make improvements in weight without the need for formal medical intervention, increase the proportion of older people who feel supported to manage their own conditions and improving the quality of life for service users and carers. This simple signposting tool that comes with a wealth of information, aligns a shared vision we have with Age UK, of a world in which older people flourish; a world in which older people have the opportunity to live healthier, longer lives and to enjoy a sense of wellbeing while maintaining choice and independence.

The PaperWeight Armband is lightweight, can be easily stored and transported and complies with infection control guidelines for single use only, as well as being easily recycled. There is a QR code on the armband so that it can be scanned to directly access the dietary leaflet on the Age UK Salford website that has proven to be invaluable to Salford health and social care professionals seeking ‘food first’ approaches to dealing with the risk of malnutrition. The guidance outlined in the leaflet should be followed for a maximum of 12 weeks, following which time, if there is no improvement, the advice is to ask to see a healthcare professional. It can be used when scales and height charts are not available, when support workers are short on time with a whole day of scheduled visits or, if someone is reluctant to be measured, for example, a person with dementia.

CAsE sTUdIEs Case study evidence has shown how well the PaperWeight Armband works as a signposting tool and how it leads to further support. One woman was able to get back on her feet after the early intervention of the armband. The 91-year-old who lives alone, spent a period of time in hospital and the day after she was discharged, she was called by Age UK Salford’s Hospital Discharge Aftercare and Reablement Service, who established that she was having difficulties with eating meals. During the initial home visit, discussions identified that she had lost a lot of weight and had no motivation to cook or eat well.

The Age UK Salford support worker used the PaperWeight Armband test, which identified that she was at risk of malnutrition. She was provided with the nutrition booklet, ‘How to improve your food and drink intake if you have a poor appetite’ and over the following eight weeks, the support worker visited her to encourage her to increase her nutritional intake. At the end of the eightweek period, she had gained 4kg in weight, was making home cooked meals two or three times

The hope now is that the hard work that Salford has pioneered to help fight malnutrition will spearhead an integrated approach to dealing with it . . .

a week and went out with her friend regularly, including a lunch group. The woman reported improved confidence; reduced attendance at her GP; more independence and a renewed interest in food and nutrition again.

Another case study has also shown how well the PaperWeight Armband and supporting information works to help fight malnutrition. A 65-year-old man with learning difficulties had lost weight unintentionally, which was noticed by his carers. It was established that his housemates were on a weight-reducing regimen, therefore, the communal food in the fridge, such as milk, butter and cheese, had been changed to low-fat varieties and sugar had been replaced with an artificial sweetener. His carers sought advice from Age UK Salford and then used the PaperWeight Armband to establish that he was at risk, then simple changes were made with help from the nutrition booklet. This resulted in him gaining 7kg in weight over a 12-month period and he also started to enjoy his food again.

These two examples not only show how quick and easy the PaperWeight Armband is to use, it also shows how effective it is as a non-medical, non-intrusive tool that is a starting point to help health- and social care professionals - as well as family carers - fight malnutrition.

JOINEd-UP CARE AT sAlfORd As a vanguard site, Salford Royal NHS Foundation Trust is set to be at the forefront of a national health revolution that will bring home care, mental health and community nursing, hospital and outof-hospital services together, ushering in a new era of joined-up care. Together, we believe that prevention and treatment of malnutrition should be integral to ensure that older people can live more independent, fulfilling lives.

The hope now is that the hard work that Salford has pioneered to help fight malnutrition will spearhead an integrated approach to dealing with it, helping to save lives and reducing costs - all starting with a simple strip of paper. The armbands can be bought by healthcare providers in packs, along with the handbook, nutrition booklets and a poster that can be displayed in a workplace to show it is being used. For more information on the PaperWeight Armband and to view a short video on the background to the product development, go to the following link. www.ageuk.org.uk/salford where you can also register for more information and a starter pack.

TOP TIPs fOR sERVICE UsERs TO ImPROVE INTAkE (Taken from the PaperWeight Armband supporting booklet: How to improve your food and drink intake if you have a poor appetite) • Have small regular meals and snacks in between. • Try to eat something every two to three hours, even if it is only something small. • Have puddings or desserts at least once a day, if you are too full after a meal, wait 30 minutes. • Alcohol in small amounts can stimulate an appetite, but it is important to check with a doctor or chemist if taking any medication. • If you smoke, try not to smoke in the half hour before a meal. • Getting a small amount of fresh air before meals can help to stimulate an appetite. • Take drinks after meals rather than before or with to avoid feeling too full or bloated. • Make the most of ‘good days’ or times during the day when you feel more like eating. • Enriched nutritional drinks, for example,

Complan and Build Up, are available to buy from chemists and supermarkets and are available in a wide-range of preparations, including flavoured drinks and soups. • If after four weeks of trying some of the suggestions to your diet, you are still concerned or losing weight, contact your GP practice.