46 Questions
What is the prevalence of obesity in adult women in the United States according to the National Health and Nutrition Examination Survey 2009-2010?
35.8%
When was obesity recognized as a disease by the American Medical Association?
June 2013
What is the purpose of the clinical guideline discussed in the content?
To serve as a framework for the nutrition support care of adult patients with obesity
What is the process used to develop the clinical guideline recommendations?
Consensus process involving consideration of evidence and patient benefits
What is the percentage of adult men with a body mass index (BMI) ≥ 40 kg/m2 according to the National Health and Nutrition Examination Survey 2009-2010?
4.4%
What is the focus of the questions addressed in the systematic review?
Management of nutrition support in patients with obesity
What is the name of the working group whose concepts were adopted for evaluating the evidence?
Grading of Recommendations, Assessment, Development and Evaluation
What is the term used to describe a surgical procedure that is intended to reduce nutrient absorption?
Malabsorptive procedure
What percentage of adult patients in the United States are treated with bariatric surgery annually?
Approximately 200,000 adults
What is the recommended time frame for nutrition assessment and development of a nutrition support plan for critically ill patients with obesity?
Within 48 hours of ICU admission
What is the primary purpose of this clinical guideline?
To guide clinicians on the nutrition support care of hospitalized adult patients who have obesity
What is the evidence grade for the recommendation that all hospitalized patients, regardless of BMI, should be screened for nutrition risk within 48 hours of admission?
Low
According to the available studies, what is the trend in mortality outcomes for obese ICU patients?
Varied results, with some studies showing increased mortality and others showing reduced mortality
What is the rationale for recommending early nutrition assessment and care plan for critically ill patients with obesity?
Because clinical outcomes in patients with obesity may be impacted by numerous factors
What is the limitation of the available studies comparing outcomes of mortality, length of stay, and complications in obese ICU and non-ICU patients?
Retrospective database evaluation and relatively small number of obese subjects
What is the trend in length of stay (LOS) in the ICU for obese patients compared to non-obese patients?
No difference in LOS between obese and non-obese patients
What is the trend in complications for obese patients compared to non-obese patients in ICU and non-ICU settings?
Varied results, with some studies showing more complications and others showing no difference
What is the implication of the available studies on adjunctive nutrition care for obese patients?
Adjunctive nutrition care should be initiated earlier due to increased risk of complications
Which of the following micronutrients has NOT been documented to increase in deficiency as the degree of obesity increases in populations who have had no prior bariatric surgery?
Vitamin E
What is the recommended daily dose of vitamin D for all bariatric surgery patients?
3000 IU
Which of the following patients do not need to take 1200-1500 mg calcium citrate daily?
Patients with BPD
What is the recommended frequency of evaluation of folic acid, iron, and 25-hydroxyvitamin D?
Annually
Which of the following micronutrients should be monitored when patients have specific findings to suggest deficiency?
Copper, zinc, selenium, and thiamine
What is the percentage of compliance with supplement ingestion in patients with BPD ± DS?
55%
What is the trend of patient follow-up with bariatric surgical programs over time?
It decreases with time duration after the surgical procedure
What is the current status of data evaluating micronutrient status in patients in the decades following bariatric surgical intervention?
Not available
What is the main difference between hypocaloric and eucaloric feeding?
Hypocaloric feeding provides a caloric intake less than measured or estimated energy expenditure, whereas eucaloric feeding provides a caloric intake sufficient to meet caloric needs.
What is the primary concern for hospitalized patients with obesity?
Overfeeding complications
What is the purpose of nitrogen balance studies in hypocaloric high protein feeding?
To adjust the goal protein intake
What is the difference between malabsorptive and restrictive surgical procedures for weight loss?
Malabsorptive procedures shorten the small bowel absorptive capacity, while restrictive procedures reduce the capacity of the stomach
What is the recommended evaluation for acutely ill hospitalized patients with a history of malabsorptive or restrictive surgical procedures for weight loss?
Evaluation for evidence of depletion of iron, copper, zinc, selenium, thiamine, folate, and vitamins B12, and D
What is the characteristic of hypocaloric high protein feeding?
Provision of a caloric intake less than measured or estimated energy expenditure
What is the purpose of the MSJ equations?
To estimate the patient's energy requirements
What is the recommended starting point for hypocaloric feeding?
50%-70% of estimated energy requirements
What is the evidence grade for the recommendation on hypocaloric high protein feeding?
Low
What is the primary concern for hypocaloric low protein feedings?
Unfavorable outcomes
What is the primary goal of nutrition assessment in hospitalized patients?
To avoid energy overfeeding
What is the recommended method for measuring resting energy expenditure (REE) in patients?
Indirect calorimetry
In critically ill obese patients, which equation is recommended for estimating energy requirements if indirect calorimetry is unavailable?
Penn State University 2010 predictive equation
What is the accuracy rate of the Penn State University equation in predicting REE in critically ill patients with BMI ≥ 30 kg/m2?
70% (± 10% of REE)
In older critically ill obese patients (≥ 60 years), which equation is more accurate than the original Penn State University equation?
Modified Penn State University equation
What is the purpose of the Mifflin-St Jeor equation in the Penn State University equations?
To calculate resting metabolic rate (RMR)
What is the name of the equation that is recommended for estimating energy requirements in hospitalized obese patients if indirect calorimetry is unavailable and the Penn State University equations cannot be used?
Mifflin-St Jeor equation
What is the evidence grade for the recommendation to use the Penn State University 2010 predictive equation in critically ill obese patients?
High
What is the purpose of nutrition support interventions in hospitalized obese patients?
To improve clinical outcomes
What is the recommended frequency for measuring REE in critically ill patients?
Continuously for 7 days
Study Notes
Background and Purpose
- Obesity is a disease that requires medical treatment, recognized by the American Medical Association in 2013.
- The prevalence of obesity in the United States is 35.5% in adult men and 35.8% in adult women, including 4.4% and 8.2% respectively with BMI ≥ 40 kg/m2.
- Nutrition support clinicians are likely to care for obese patients, particularly during hospital admissions.
- The purpose of this clinical guideline is to guide clinicians on the nutrition support care of hospitalized adult patients who have obesity.
Question 1: Do Clinical Outcomes Vary Across Levels of Obesity?
- Critically ill patients with obesity experience more complications than patients with optimal BMI levels.
- Nutrition assessment and development of a nutrition support plan is recommended within 48 hours of ICU admission (strong).
- All hospitalized patients, regardless of BMI, should be screened for nutrition risk within 48 hours of admission, with nutrition assessment for patients who are considered at risk (strong).
Question 2: How Should Energy Requirements Be Determined?
- In the critically ill obese patient, energy requirements should be based on the Penn State University 2010 predictive equation or the modified Penn State University equation if the patient is over the age of 60 years (strong).
- In the hospitalized obese patient, energy requirements may be based on the Mifflin-St Jeor equation using actual body weight (weak).
Question 3: Are Clinical Outcomes Improved With Hypocaloric, High Protein Diets?
- Clinical outcomes are at least equivalent in patients supported with high protein hypocaloric feeding to those supported with high protein eucaloric feeding (weak).
- Hypocaloric high protein feeding may be started with 50%-70% of estimated energy requirements or < 14 kcal/kg actual weight, and high protein feeding may be started with 1.2 g/kg actual weight or 2–2.5 g/kg ideal body weight.
Question 4: In Obese Patients Who Have Had Malabsorptive or Restrictive Surgical Procedures
- Patients who have undergone sleeve gastrectomy, gastric bypass, or biliopancreatic diversion ± duodenal switch have increased risk of nutrient deficiency.
- Evaluation for evidence of depletion of iron, copper, zinc, selenium, thiamine, folate, and vitamins B12, and D is suggested in acutely ill hospitalized patients with history of these procedures (weak).
- Daily multiple vitamin/mineral supplements are recommended, and specific nutrient supplements should be taken according to the type of procedure and individual patient needs.
Learn about the clinical guideline for nutrition support care of adult patients with obesity during hospitalization. Understand the framework for management of nutrition support in patients with obesity.
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