Ashraf El Houfi .

MD
MS (pulmonology) MRCP (UK)
FRCP (london) EDIC
Consultant / Head ICU Dubai Hospital
 Facts
• One third of all adults
are obese,
• One in six children are
overweight or obese.
• Reflecting this reality,
• 30-35% of adult ICU
patients are obese, and
5% or more are
morbidly obese
 Challenges
• Critically ill, morbidly
obese present unique
challenges to care.
• Basic care, prevention
of bedsores, ambulation,
medication dosing and
ventilator management
• One of difficult aspects
is nutrition support.
 So,
why nutrition is a problem?
• After all, obese patients have
large amounts of stored calories.
• Can’t they live off their fat?

• Should we consider that critical illness

as golden opportunity to loose weight !
 Facts
• Obese ICU patients have problems with fuel
utilization, which predisposes them to greater loss of
lean body mass.
• Obese subjects in a SICU derived only 39% of their
REE from fat metabolism, compared to higher
percentage of energy needs from protein metabolism
indicating greater potential for erosion of lean body
mass.

Jeevanandam M, et al. Obesity and the metabolic response to severe multiple trauma. J Clin Invest 1991
Hutagalung R, et al. The obesity paradox in surgical ICU patients. Intensive Care Med. 2011.
 When ?

• Based on expert consensus, we suggest that

early EN start within 24–48 hours of
admission to the ICU for obese patients who
cannot sustain volitional intake.

Stephen A. McClave et al, Guidelines for the Provision and Assessment of Nutrition
Support Therapy in the Adult Critically Ill Patient: (SCCM) (A.S.P.E.N.) February 2016
 EN should be delayed
• Shock is uncontrolled and hemodynamic & tissue
perfusion goals are not reached,
• Life-threatening hypoxemia, hypercapnia, acidosis
• Active upper GI bleeding;
• Overt bowel ischemia;
• High-output intestinal fistula if reliable feeding
access distal to the fistula is not achievable;
• Abdominal Compartment Syndrome;
• if gastric aspirate volume is above 500 ml/6 h.
 Nutrition Assessment
Obese ICU patient
• Beyond BMI.
• Biomarkers of metabolic syndrome should be
evaluated, glucose, triglyceride, cholesterol.
• Preexisting & emerging comorbidities,
DM, OSA, CHF, HTN, thrombogenesis & abnormal
liver enzymes to suggest fatty liver disease.
• An assessment of the level of inflammation should be
done by looking at CRP, ESR, and evidence of SIRS.
 Energy Needs?
• We suggest that Indirect Calorimetry (IC) be used to
determine energy requirements, when available

Stephen A. McClave et al, Guidelines for the Provision and Assessment of Nutrition
Support Therapy in the Adult Critically Ill Patient: (SCCM) (A.S.P.E.N.) February 2016
 Energy Needs?
• If Calorimetry is not available, using
VO2 (oxygen consumption) from PA catheter
or
VCO2 (carbon dioxide production) derived
from the ventilator will give a better
evaluation on EE than predictive equations.

• REE = VCO2 x 8.19

Pierre Singer et al; ESPEN guideline on clinical nutrition in the intensive care unit
Clinical Nutrition 2018
 ASPEN 2013
• In the critically ill obese patient, if IC is
unavailable energy requirements should be
based on the Penn State University 2010
predictive equation.
• Penn State University equations cannot be
used, energy requirements may be based on
the Mifflin–St Jeor equation using actual
body weight
 Penn state & Mifflin–St Jeor

• Penn state equations Global ( BMI≥30kg/m²)

• RMR = Mifflin(0.71) + VE (64) + Tmax(85) – 3085
• RMR = Mifflin(0.96) + VE(31) + Tmax(167) – 6212
• Mifflin
• ♂: 10×(weight)+6.25×(height)−5×(age)+5
• ♀: 10×(weight)+6.25×(height)−5×(age)−16
• Men: RMR = 10(W) (H) – 5(A) + 5
• Women: RMR = 10(W) (H) – 5(A) -16
• х AF (study or population-specific activity factor)
 Energy Needs?
• If IC is unavailable, we suggest using the
weight-based equation

11–14 kcal/kg actual body weight /day for

patients with BMI of 30–50 and

22–25 kcal/kg ideal body weight / day for

patients with BMI >50.
Stephen A. McClave et al, Guidelines for the Provision and Assessment of Nutrition
Support Therapy in the Adult Critically Ill Patient: (SCCM) (A.S.P.E.N.) February 2016
 Hypocaloric?
• Achieving some degree of weight loss may
increase insulin sensitivity, facilitate nursing
care, and reduce risk of comorbidities.
Providing 60%–70% of caloric requirements
promotes steady weight loss.
 Evidence
• Study of 40 obese critically ill surgical and trauma
patients, use of high-protein hypocaloric EN was
associated with shorter ICU stay, decreased duration
of antibiotics, and fewer days of mechanical
ventilation compared with use of a high-protein
eucaloric diet
• < 20 Kcal/kg > 20Kcal/kg

Dickerson RN, et al, Hypocaloric enteral tube feeding in critically ill obese patients. Nutrition.
2002;18(3):241-246.
 Evidence
• 2 RCTs, use of a parenteral high-protein
hypocaloric diet resulted in similar outcomes
(hospital LOS and mortality) as compared to a high-
protein eucaloric PN regimen

* Choban PS, et al. Hypoenergetic nutrition support in hospitalized obese patients: a simplified
method for clinical application. Am J Clin Nutr. 1997;66(3):546-550.
* Ahrens CL, et al. Effect of low-calorie parenteral nutrition on the incidence and severity of
hyperglycemia in surgical patients: a randomized, controlled trial. Crit Care Med. 2005;33(11):2507-
 Guidelines
• The current literature indicates that Hypocaloric, high-
protein enteral or parenteral nutrition is promising as
the standard of practice for the metabolic support of the
critically ill obese patient.

• Therefore, Hypocaloric and hyperproteic nutrition,

whether enteral or parenteral, should be standard
practice in the nutritional support of critically-ill obese
patients.
** Choban P, et al;. A.S.P.E.N. clinical guidelines: nutrition support of hospitalized adult patients
with obesity. JPEN. 2013
** Mesejo A, et al ; Guidelines for specialized nutritional support in critically-ill obese patient :
Consensus :. Nutr Hosp. 2011 Nov;26 Suppl 2:54-8 (SEMICYUC-SENPE)
Validation of the SCCM and ASPEN Recommendations
for Caloric Provision to Critically Ill Obese Patients.

SCCM/ASPEN-recommended body weight equations are

reasonable predictors of 65% MREE. this study suggests
that patients with a
BMI 30-50 should receive 11-14 kcal/kg/d using ABW
and those with a
BMI >50 should receive 22-25 kcal/kg/d using IBW.

Mogensen KM et al JPEN J Parenter Enteral Nutr. 2016 Jul;40(5):713-21

Boston, Massachusetts
 Not only Obese
• Hypocaloric nutrition (not exceeding 70% of
EE) should be administered in the early
phase of acute illness.
• Grade of recommendation: B strong consensus (100% agreement)

• After day 3, caloric delivery can be increased

up to 80-100% of measured EE.
• Grade of recommendation: 0 strong consensus (95% agreement)

Pierre Singer et al; ESPEN guideline on clinical nutrition in the intensive care unit
Clinical Nutrition 2018
• If predictive equations are used to estimate
the energy need, Hypocaloric nutrition (below
70% estimated needs) should be preferred
over Isocaloric nutrition for the first week of
ICU stay.
• Grade of recommendation B e strong consensus (95% agreement)

Pierre Singer et al; ESPEN guideline on clinical nutrition in the intensive care unit
Clinical Nutrition 2018
• Actual EE should not be the target during the
first 72 h of acute critical illness.
• Early full feeding causes overfeeding as it
adds to the endogenous energy production
which amounts to 500-1400 kcal/day

Pierre Singer et al; ESPEN guideline on clinical nutrition in the intensive care unit
Clinical Nutrition 2018
 ESPEN 2018
• An iso-caloric high protein diet can be
administered to obese patients,
• In obese patients, energy intake should be
guided by indirect calorimetry.
• If indirect calorimetry is not available,
energy intake can be based on
“adjusted body weight”.
 Rational
• Adipose tissue utilizes 4.5 kcal/kg/day and
muscle 13 kcal/kg/day .
• The proportion of muscle within the excess
weight of an obese individual might be
roughly 10%.
• A pragmatic approach is to add 20-25% of the
excess weight (ABW-IBW) to IBW for all
calculations of energy requirements.
 165

ASPEN 2016
Energy 11-14 /kg Actual BW 1680 kcal
ESPEN 2018
Energy 20-25 /kg adjusted BW 1870kcal
Patient Metrics BMI 43.2 kg/m2
Height 180 cm Ideal body weight 75.1 kg
B. wt. 140 kg Adjusted weight 100 kg
Gender Male BSA 2.65 m2

ASPEN
Energy 11-14 kcal/kg 14x140 = 1960 kcal

ESPEN
Energy 20-25 kcal/kg (Adjusted BW) = 2220 kcal
 How Much (protein)
• We suggest that sufficient
(high-dose) protein should be provided.
• We suggest that protein should be provided in a
range from
2.0 g/kg ideal body weight / day for patients with
BMI of 30–40 up to
2.5 g/kg ideal body weight / day for patients with
BMI ≥40.

Stephen A. McClave et al, Guidelines for the Provision and Assessment of Nutrition
Support Therapy in the Adult Critically Ill Patient: (SCCM) (A.S.P.E.N.) February 2016
 How Much (protein)
• Protein delivery should be guided by urinary
nitrogen losses or lean body mass determination
(using CT or other tools).
• If urinary nitrogen losses or lean body mass
determination are not available, protein intake
can be 1.3 g/kg “adjusted body weight”/d.

Pierre Singer et al; ESPEN guideline on clinical nutrition in the intensive care unit
Clinical Nutrition 2018
Height 175 cm Ideal body weight 70.5 kg
Body weight 160 kg Adjusted weight 106.3 kg
Gender Male BMI 52.2 kg/m2
BSA 2.79 m2

ASPEN
Energy 22-25 kcal/kg IBW 1750 kcal/day
Protein 2.5g/kg IBW 175g/day
ESPEN
Energy 20-25 kcal/kg Adjusted BW 2100 kcal/day
Protein 1.3 gm/kg adjusted BW 138 g/day
 Metabolic Response to Stress
28
24
20
Nitrogen excretion (g/day)

16
12
8
4
0

10 20 30 40
Days
Long CL, et al. JPEN J Parenter Enteral Nutr 1979;3:452–456.
Metabolic Response to Stress
How Much Protein?

Loss of
total body protein
(in vivo neutron
Activation)

Ishibashi, et al. Crit Care Med 1998;26:1529–1535.

 Effect of high protein enteral nutrition
on LBM in ICU
AA administration /kg LBM AA administration /kg LBM

1,1 g 1,5 g 1,1 g 1,5 g

0 0

Loss of muscle protein (%)

Loss of muscle protein

-0.4 -0.8 -4
(kg) in 10 days

in 10 days
-0.8
-1.8 -8
-7.8
-1.2
-12
-1.6

-16 -14.8
-2

-1.8 kg of proteins reflects 9 kg of muscle mass

Ishibashi, et al. Crit Care Med 1998;26:1529–1535.

 • Both groups were fed according to energy expenditure
• Muscle protein turnover was measured and calculated using labelled phenylalanine (Phe)
• Bars demonstrate a similar muscle protein synthesis rate, but a different protein
degradation rate (P < 0.05), resulting in a different protein balance (P < 0.05)

Rooyackers O, Wernerman J. Crit Care 2014;18:144.

 Histological changes in skeletal muscles
after ICU admission
• Muscle wasting occurred early and rapidly and was more severe among those with
multiorgan failure compared with single organ failure

Puthucheary ZA, et al. JAMA 2013;310:1591–1600.

 LBM (CT-scan) and mortality

Low skeletal muscle area, as assessed by CT scan during the early stage of
critical illness, is a risk factor for mortality in mechanically ventilated critically
ill patients, Further analysis suggests muscle mass as primary predictor.

Weijs PJ, et al. Crit Care 2014;18:R12.

Loss of LBM is devastating
Overall performance: Kcals for first
2 weeks in ICU
Average Protein Delivery

0.6 g/kg/d
for 2 weeks in ICU!
 Optimal protein and energy nutrition decreases mortality in
mechanically ventilated, critically ill patients: a prospective
observational cohort study.
Weijs PJ, Stapel SN, de Groot SD, Driessen RH, de Jong E, Girbes AR, Strack van Schijndel RJ, Beishuizen A.

Netherlands
JPEN J Parenter Enter Nutr 2012;36:60–68.
MORTALITY

• 28-day mortality hazard ratio with 95% confidence interval for protein and
energy target (PET) group and energy target (ET) group. Model 0 is
unadjusted. Model 1 adjusted for sex, age, BMI, diagnosis, hyperglycemic
index and Acute Physiology and Chronic Health Evaluation II score. Model 2
additionally adjusted for time to energy target and use of parenteral nutrition.
Copenhagen, Denmark Clin Nutr 2012;31:462–468.

• 113 select ICU patients with sepsis or burns

• On average, receiving 1900 kcal/day and 84 grams of
protein
• No significant relationship with energy intake but…
 Prospective observational cohort study of 113 ICU
patients

114.9 g/day (1.46 g/kg/day)

P = 0.021

84.3 g/day (1.06 g/kg/day)

53.8 g/day (0.80 g/kg/day)

Log-rank test for trend: P < 0.01

Allingstrup MJ, et al. Clin Nutr 2012;31:462–468.

 Increased protein delivery reduces mortality in
ICU patients

Allingstrup MJ, et al. Clin Nutr 2012;31:462–468.

 Protein, energy and mortality
Protein & AA / kg actual body weight : HR 0.31 (95%CI: 0.10-0.96), P=0.043

Survival was dependent on provision of protein & AA even when adjusted for APACHE II score,
average SOFA score and age. It was unrelated energy balances.

Allingstrup MJ, et al. Clin Nutr 2012;31:462–468.

 Monitoring
• Based on expert consensus, we suggest additional
monitoring for hyperglycemia, hyperlipidemia,
hypercapnia, fluid overload, and hepatic fat
accumulation in the obese critically ill patient receiving
EN.
• It is imperative to assess nutrition efficacy. Repeating IC
measurements, or VCO2 (carbon dioxide production) to
maintain energy provision at 65%–70% of REE is
important.
• Protein delivery should be guided by urinary nitrogen
losses or lean body mass determination (using CT or
other tools).
 Monitoring
• In addition, evaluation for and treatment of
micronutrient deficiencies such as
calcium, thiamin, vitamin B12, fat soluble vitamins
(A, D, E, K), and folate, along with the trace
minerals iron, selenium, zinc, and copper,
should be considered.
DR.Ashraf Elhoufi
ICU Dubai Hospital
References
1. McClave SA, et al. Guidelines for the provision and assessment of nutrition support
therapy in the adult critically ill patient: (SCCM) and (A.S.P.E.N.). JPEN 2009; 2016.
2. Pierre Singer et al; ESPEN guideline on clinical nutrition in the intensive care unit
Clinical Nutrition 2018
3. Dhaliwal R, et al. The Canadian critical care nutrition guidelines in 2013: an update.
Nutr Clin Pract. 2014;29(1):29-43.
4. Jeejeebhoy KN. Permissive underfeeding of the critically ill patient. Nutr Clin Pract.
2004;19(5):477-480..
5. Choban PS, Burge JC, Scales D, Flancbaum L. Hypoenergetic nutrition support in
hospitalized obese patients: a simplified method for clinical application. Am J Clin
Nutr. 1997;66(3):546-550.
6. Kee AL, Isenring E, Hickman I, Vivanti A. Resting energy expenditure of morbidly
obese patients using indirect calorimetry: a systematic review. Obes Rev. 2012.
7. McClave SA, Kushner R, Van Way CW 3rd, et al. Nutrition therapy of the severely
obese, critically ill patient: summation of conclusions and recommendations. JPEN J
Parenter Enteral Nutr. 2011;35(5):88S-96S.
8. Choban P, Dickerson R, Malone A, Worthington P, Compher C; American Society for
Parenteral and Enteral Nutrition. A.S.P.E.N. clinical guidelines: nutrition support of
hospitalized adult patients with obesity. JPEN J Parenter Enteral Nutr.
2013;37(6):714-744
 • Point prevalence survey of nutrition practices in
ICU’s around the world conducted Jan. 27, 2007

• 2772 patients from 158 ICUs over 5 continents

• Included ventilated adult patients who remained

in ICU >72 hours
Alberda C, et al. Intensive Care Med 2009;35:1728–1737.
 Relationship of protein/caloric intake, 60-day
mortality and BMI
60
All Patients
BMI < 20
50
20-25
25-30
40 30-35
Mortality (%)

35-40
>40
30

20

10 25% 50% 75% 100%

0
0 500 1000 1500 2000
Protein/calories delivered
Alberda C, et al. Intensive Care Med 2009;35:1728–1737.