Journal of Parenteral and Enteral A.S.P.E.N. Clinical...
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Journal of Parenteral and Enteral Nutrition Volume 37 Number 6 November 2013 714–744 © 2013 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0148607113499374 jpen.sagepub.com hosted at online.sagepub.com Clinical Guidelines Background As of June 2013, the American Medical Association recog- nized obesity as a disease that requires medical treatment. 1,2 Based on the National Health and Nutrition Examination Survey 2009-2010, the prevalence of obesity in the United States is 35.5% in adult men, 35.8% in adult women, including 4.4% and 8.2% respectively with body mass index (BMI) ≥ 40 kg/m 2 . 3 Thus, nutrition support clinicians are likely to care for obese patients, particularly during hospital admissions. While nutrition support clinicians care for patients across a broad range of clinical settings, the bulk of publications available for this clinical guideline have come from hospitalized patients. Furthermore, since the clinical acuity of patients admitted to intensive care units (ICUs) is much higher than those who are not critically ill, for this guideline most recommendations have been made separately for these 2 groups of obese hospitalized patients when data were available. Bariatric surgery is a common treatment for patients who have severe obesity, with estimates of approximately 200,000 adults treated with bariatric surgery annually in the United States. 4 Since these procedures are designed to limit the patient’s nutrient intake as a strategy to promote significant and durable weight loss, patients treated with these procedures may require nutrition care. Thus, the purpose of this clinical guideline is to guide clinicians on the nutrition support care of hospitalized adult patients who have obesity. 499374PEN XX X 10.1177/0148607113499374Journal of Parenteral and Enteral Nutrition XX(X)Choban et al research-article 2013 From 1 Mt Carmel Hospital, Central Ohio Surgical Associates, Columbus, OH, USA; 2 University of Tennessee Health Science Center, Memphis, TN, USA; 3 Department of Pharmacy, Mt Carmel West Hospital, Columbus, OH, USA; 4 Thomas Jefferson University Hospital, Philadelphia, PA, USA; and 5 University of Pennsylvania School of Nursing, Philadelphia, PA, USA. The A.S.P.E.N. Clinical Guidelines Editorial Board guided the development of and review of these guidelines using the GRADE system. The A.S.P.E.N. Board of Directors approved the guidelines on June 26, 2013. Financial disclosure: None declared. Speaker’s Bureau: Nestlé (RND); Abbott (AM) Received for publication July 5, 2013; accepted for publication July 5, 2013. This article originally appeared online on August 23, 2013. Corresponding Author: Charlene Compher, PhD, RD, CNSD, LDN, FADA, FASPEN, Professor of Nutrition Science, University of Pennsylvania School of Nursing, Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104-4217, USA. Email: [email protected] A.S.P.E.N. Clinical Guidelines: Nutrition Support of Hospitalized Adult Patients With Obesity Patricia Choban, MD 1 ; Roland Dickerson, PharmD, BCNSP 2 ; Ainsley Malone, MS, RD, CNSC 3 ; Patricia Worthington, MSN, RN 4 ; Charlene Compher, PhD, RD, CNSC, LDN, FADA, FASPEN 5 ; and the American Society for Parenteral and Enteral Nutrition Abstract Background: Due to the high prevalence of obesity in adults, nutrition support clinicians are encountering greater numbers of obese patients who require nutrition support during hospitalization. The purpose of this clinical guideline is to serve as a framework for the nutrition support care of adult patients with obesity. Method: A systematic review of the best available evidence to answer a series of questions regarding management of nutrition support in patients with obesity was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process, that includes consideration of the strength of the evidence together with the risks and benefits to the patient, was used to develop the clinical guideline recommendations prior to multiple levels of external and internal review and approval by the A.S.P.E.N. Board of Directors. Questions: (1) Do clinical outcomes vary across levels of obesity in critically ill or hospitalized non–intensive care unit (ICU) patients? (2) How should energy requirements be determined in obese critically ill or hospitalized non-ICU patients? (3) Are clinical outcomes improved with hypocaloric, high protein diets in hospitalized patients? (4) In obese patients who have had a malabsorptive or restrictive surgical procedure, what micronutrients should be evaluated? (JPEN J Parenter Enteral Nutr. 2013;37:714-744) Keywords adult; life cycle; calorimetry; nutrition; assessment; outcomes; research/quality; support practice; obesity
Transcript of Journal of Parenteral and Enteral A.S.P.E.N. Clinical...
Journal of Parenteral and EnteralNutritionVolume 37 Number 6 November 2013 714 –744© 2013 American Societyfor Parenteral and Enteral NutritionDOI: 10.1177/0148607113499374jpen.sagepub.comhosted at online.sagepub.com
Clinical Guidelines
Background
As of June 2013, the American Medical Association recog-nized obesity as a disease that requires medical treatment.1,2 Based on the National Health and Nutrition Examination Survey 2009-2010, the prevalence of obesity in the United States is 35.5% in adult men, 35.8% in adult women, including 4.4% and 8.2% respectively with body mass index (BMI) ≥ 40 kg/m2.3 Thus, nutrition support clinicians are likely to care for obese patients, particularly during hospital admissions. While nutrition support clinicians care for patients across a broad range of clinical settings, the bulk of publications available for this clinical guideline have come from hospitalized patients. Furthermore, since the clinical acuity of patients admitted to intensive care units (ICUs) is much higher than those who are not critically ill, for this guideline most recommendations have been made separately for these 2 groups of obese hospitalized patients when data were available.
Bariatric surgery is a common treatment for patients who have severe obesity, with estimates of approximately 200,000 adults treated with bariatric surgery annually in the United States.4 Since these procedures are designed to limit the patient’s nutrient intake as a strategy to promote significant and durable weight loss, patients treated with these procedures may require nutrition care. Thus, the purpose of this clinical
guideline is to guide clinicians on the nutrition support care of hospitalized adult patients who have obesity.
499374 PENXXX10.1177/0148607113499374Journal of Parenteral and Enteral Nutrition XX(X)Choban et alresearch-article2013
From 1Mt Carmel Hospital, Central Ohio Surgical Associates, Columbus, OH, USA; 2University of Tennessee Health Science Center, Memphis, TN, USA; 3Department of Pharmacy, Mt Carmel West Hospital, Columbus, OH, USA; 4Thomas Jefferson University Hospital, Philadelphia, PA, USA; and 5University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
The A.S.P.E.N. Clinical Guidelines Editorial Board guided the development of and review of these guidelines using the GRADE system. The A.S.P.E.N. Board of Directors approved the guidelines on June 26, 2013.
Financial disclosure: None declared.
Speaker’s Bureau: Nestlé (RND); Abbott (AM)
Received for publication July 5, 2013; accepted for publication July 5, 2013.
This article originally appeared online on August 23, 2013.
Corresponding Author:Charlene Compher, PhD, RD, CNSD, LDN, FADA, FASPEN, Professor of Nutrition Science, University of Pennsylvania School of Nursing, Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104-4217, USA. Email: [email protected]
A.S.P.E.N. Clinical Guidelines: Nutrition Support of Hospitalized Adult Patients With Obesity
Patricia Choban, MD1; Roland Dickerson, PharmD, BCNSP2; Ainsley Malone, MS, RD, CNSC3; Patricia Worthington, MSN, RN4; Charlene Compher, PhD, RD, CNSC, LDN, FADA, FASPEN5; and the American Society for Parenteral and Enteral Nutrition
AbstractBackground: Due to the high prevalence of obesity in adults, nutrition support clinicians are encountering greater numbers of obese patients who require nutrition support during hospitalization. The purpose of this clinical guideline is to serve as a framework for the nutrition support care of adult patients with obesity. Method: A systematic review of the best available evidence to answer a series of questions regarding management of nutrition support in patients with obesity was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process, that includes consideration of the strength of the evidence together with the risks and benefits to the patient, was used to develop the clinical guideline recommendations prior to multiple levels of external and internal review and approval by the A.S.P.E.N. Board of Directors. Questions: (1) Do clinical outcomes vary across levels of obesity in critically ill or hospitalized non–intensive care unit (ICU) patients? (2) How should energy requirements be determined in obese critically ill or hospitalized non-ICU patients? (3) Are clinical outcomes improved with hypocaloric, high protein diets in hospitalized patients? (4) In obese patients who have had a malabsorptive or restrictive surgical procedure, what micronutrients should be evaluated? (JPEN J Parenter Enteral Nutr. 2013;37:714-744)
Keywordsadult; life cycle; calorimetry; nutrition; assessment; outcomes; research/quality; support practice; obesity
Choban et al 715
Method
The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is an organization comprised of healthcare profes-sionals representing the disciplines of medicine, nursing, phar-macy, dietetics, and nutrition science. The mission of A.S.P.E.N. is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. A.S.P.E.N. vigorously works to support quality patient care, education, and research in the fields of nutrition and metabolic support in all healthcare settings. These clinical guidelines were devel-oped under the guidance of the A.S.P.E.N. Board of Directors. Promotion of safe and effective patient care by nutrition sup-port practitioners is a critical role of the A.S.P.E.N. organiza-tion. A.S.P.E.N. has been publishing clinical guidelines since 1986.5-15
These A.S.P.E.N. clinical guidelines are based on general conclusions of health professionals who, in developing such guidelines, have balanced potential benefits to be derived from a particular mode of medical therapy against certain risks inherent with such therapy. However, the professional judg-ment of the attending health professional is the primary com-ponent of quality medical care. Because guidelines cannot account for every variation in circumstances, the practitioner must always exercise professional judgment in their applica-tion. These clinical guidelines are intended to supplement, but not replace, professional training and judgment.
A.S.P.E.N. clinical guidelines has adopted concepts of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group.16-19 A full description of the methodology has been published.20 Briefly, specific clini-cal questions where nutrition support is a relevant mode of therapy are developed and key clinical outcomes are identified. A rigorous search of the published literature is conducted, each included study assessed for research quality, tables of findings developed, the body of evidence for the question evaluated and graded. Randomized controlled clinical trials are initially graded as strong evidence, but may be downgraded in quality based on study limitations. Controlled observational studies are initially graded as weak evidence, but may be graded down further based on study limitations or upgraded based on study design strengths. In a consensus process, the authors make rec-ommendations for clinical practice that are based on the evi-dence review assessed against consideration of the risks and benefits to patients. Recommendations are graded as strong when the evidence is strong and/or the risk vs benefit analysis is strong. Weak recommendations may be based on weaker evidence and/or weaker trade-offs to the patient. When limited research is available to answer a question, the recommendation is for further research to be conducted.
The guideline authors represent a range of academic and clinical expertise (medicine, dietetics, nursing, pharmacy). The external and internal expert reviewers, including the A.S.P.E.N. Board of Directors, have a similar breadth of professional expertise. This clinical guideline is planned for revision in 2018.
The questions are summarized in Table 1. With the assis-tance of a reference librarian a search was conducted in PubMed, EMBASE, and CINAHL on August 1, 2012, and updated May 2, 2013, using inclusion criteria of adult subjects, English language, randomized controlled trials, observational studies, and publications over the past 10 years. Search terms “obesity,” “clinical outcomes,” “mortality,” “infection,” “par-enteral nutrition,” and “enteral nutrition” were applied in vari-ous combinations for questions 1-3. For question 1, 31 articles met the inclusion criteria. For question 2, 9 articles that described measures in hospitalized or clinical populations of obese patients and that reported data with accuracy and bias rates were included. For question 3, the time limitation was relaxed to obtain all published information on the topic, yield-ing 8 articles. For question 4, search terms of “copper,” “zinc,” “iron,” “selenium,” “vitamin deficiency,” “nutrient defi-ciency,” “gastric bypass,” “biliopancreatic diversion,” “vita-min D,” and “bariatric surgery” were used in various combinations with a time limitation of the past 10 years, which yielded 22 articles.
Results
Question 1: Do Clinical Outcomes Vary Across Levels of Obesity in Critically Ill or Hospitalized Non-ICU Patients? (Tables 2-3)
Recommendation1a. Critically ill patients with obesity experience more
complications than patients with optimal BMI levels. Nutri-tion assessment and development of a nutrition support plan is recommended within 48 hours of ICU admission (strong).Evidence Grade: Low.
1b. 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).Evidence Grade: Low.
Rationale. Clinical outcomes in patients with obesity may be impacted by numerous factors, including comorbid conditions, associated metabolic changes and any modifications in clinical care (including nutrition support) that are made on behalf of the obese patient. The available studies comparing outcomes of mortality, length of stay (LOS), and complications in obese ICU and non-ICU patients are limited by their retrospective database evaluation,21-35 by a relatively small number of obese subjects,24-28,36-41 or by overall small sample size.22,24-28,31,34,39-43 In particular, mortality outcomes are varied, depending on these factors. To address concerns about limitations in statisti-cal power for the outcome of mortality, we considered the evi-dence from 8 studies with more than 300 obese subjects. One found increased mortality in obese trauma patients,21 5 reported reduced mortality in mixed ICU types,23,35,42,44,45 and 3 reported no difference in mortality.29,32,46 LOS in the ICU was not
716 Journal of Parenteral and Enteral Nutrition 37(6)
significantly different in obese than nonobese subjects in the single large study reporting this outcome.45 Studies with more than 300 obese patients reported more complications in obese than nonobese patients,25,47 as did 3 smaller studies in trauma patients.33,37,48 One large study in patients admitted to the med-ical ICU observed no difference in complications in obese than nonobese patients.32 These complications may impact adjunc-tive nutrition care and thus support our consensus that an early nutrition assessment (as for all critically ill patients) and care plan is indicated.
In the hospitalized, non–critically ill obese patient, 2 studies had more than 300 obese patients. One of these in surgical patients reported lower mortality and hospital
LOS,30 while a study of patients with myocardial infarction reported higher mortality and no difference in complica-tions.49 Further research is very likely to change our assess-ment of the outcomes associated with obesity in non-ICU patients. However, all patients should be screened for nutri-tion risk, and those who are at risk further assessed for nutri-tion status and potential development of a nutrition support care plan.15
Clearly, more prospective, adequately powered outcomes research is needed to clarify the risks associated with varying levels of obesity in hospitalized ICU and non-ICU patients. Studies that include measures of inflammation, body composi-tion (with a focus on lean body mass), and micronutrient status
Table 1. Nutrition Support Clinical Guideline Recommendations in Adult Patients With Obesity.
Question RecommendationRecommendation Grade and
Evidence Quality
1. Do clinical outcomes vary across levels of obesity in critically ill or hospitalized non-ICU patients?
1a. 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.
1b. 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.
Recommendation: StrongEvidence: Low
Recommendation: StrongEvidence: Low
2. How should energy requirements be determined in obese critically ill or hospitalized non-ICU patients?
2a. In the critically ill obese patient, if indirect calorimetry is unavailable, energy requirements should be based on the Penn State University 2010 predictive equation, or the modified Penn State equation if the patient is over the age of 60 years.
2b. In the hospitalized obese patient, if indirect calorimetry is unavailable and the Penn State University equations cannot be used, energy requirements may be based on the Mifflin–St Jeor equation using actual body weight.
Recommendation: StrongEvidence: High
Recommendation: WeakEvidence: Moderate
3. Are clinical outcomes improved with hypocaloric, high protein diets in hospitalized patients with obesity?
3a. Clinical outcomes are at least equivalent in patients supported with high protein, hypocaloric feeding to those supported with high protein, eucaloric feeding. A trial of hypocaloric, high protein feeding is suggested in patients who do not have severe renal or hepatic dysfunction. Hypocaloric feeding may be started with 50%-70% of estimated energy needs or < 14 kcal/kg actual weight. 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.
3b. Hypocaloric, low protein feedings are associated with unfavorable outcomes. Clinical vigilance for adequate protein provision is suggested in patients who do not have severe renal or hepatic dysfunction.
Recommendation: WeakEvidence: Low
Recommendation: WeakEvidence: Low
4. In obese patients who have had a malabsorptive or restrictive surgical procedure, what micronutrients should be evaluated?
4. Patients who have undergone sleeve gastrectomy, gastric bypass, or biliopancreatic diversion ± duodenal switch have increased risk of nutrient deficiency. In acutely ill hospitalized patients with history of these procedures, evaluation for evidence of depletion of iron, copper, zinc, selenium, thiamine, folate, and vitamins B
12 and D is
suggested as well as repletion of deficiency states.
Recommendation: WeakEvidence: Low
ICU, intensive care unit.
717
Tab
le 2
. E
vide
nce
Sum
mar
y Q
uest
ion
1: D
o C
lini
cal O
utco
mes
Var
y A
cros
s L
evel
s of
Obe
sity
in C
riti
call
y Il
l or
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pita
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atie
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dyS
tudy
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ign,
Qua
lity
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ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
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tsC
omm
ents
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pat
ien
tsN
elso
n et
al,
2012
89R
etro
spec
tive
rec
ord
revi
ewS
mal
l sam
ple
90 o
bese
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Inju
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re ≥
16
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= 3
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= 6
03●
BM
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9.9,
n =
361
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= 9
0T
otal
N =
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4
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pare
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term
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es b
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9)M
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day
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463
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9, n
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276
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119
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R 0
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86)
1-ye
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lity
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ents
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h In
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re >
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man
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6
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s no
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Tim
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th:
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mal
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s no
rmal
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01
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tali
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sed,
and
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me
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eath
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terl
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al,
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stm
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or c
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bidi
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or
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2000
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uart
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of
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MI
40-4
7.5
kg/m
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27●
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I 47
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4.6,
n =
151
● B
MI
54.7
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n =
147
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otal
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luat
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spit
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otal
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5
Ass
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s no
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ith
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ty th
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lity
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ting
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ents
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ese
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ents
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ited
sta
tist
ical
ana
lysi
s
US
Lev
el I
Tra
uma
Cen
ter
regi
stry
, pat
ient
s ov
er a
ge 4
5 ye
ars
● B
MI
< 1
8.5
kg/m
2 , n =
22
● B
MI
18.6
-24.
9, n
= 1
45●
BM
I 25
.0-2
9.9,
n =
140
● B
MI ≥
30, n
= 1
54T
otal
N =
461
Ass
ess
impa
ct o
f B
MI
on tr
aum
a ou
tcom
es,
com
plic
atio
ns, i
njur
y di
stri
buti
on, n
= 4
61
90-d
ay M
orta
lity
:●
No
stat
isti
call
y si
gnif
ican
t dif
fere
nces
acr
oss
BM
I gr
oups
in c
ompl
icat
ions
, IC
U o
r ho
spit
al L
OS
, m
orta
lity
or
disc
harg
e to
hom
e
Mar
tino
et a
l, 20
1145
Mul
tice
nter
inte
rnat
iona
l pr
ospe
ctiv
e ob
serv
atio
n st
udy
Lar
ge s
ampl
eD
ata
anal
ysis
adj
uste
d fo
r ag
e, g
ende
r, A
PA
CH
E I
I sc
ore,
dia
gnos
is c
ateg
ory,
ge
ogra
phic
reg
ion,
hos
pita
l ty
pe, I
CU
type
, pro
duct
of
age
and
AP
AC
HE
II
scor
e
Adu
lts
in 1
of
355
ICU
s fo
r m
ore
than
72
hour
s in
200
7-20
09●
BM
I <
18.
5 kg
/m2 , n
= 4
23●
BM
I 18
.5-2
4.9,
n =
349
0●
BM
I 25
-29.
9, n
= 2
604
● B
MI
30-3
9.9,
n =
177
2●
BM
I 40
-49.
9, n
= 3
48●
BM
I 50
-59.
9, n
= 1
18●
BM
I ≥
60, n
= 5
8T
otal
N =
881
3
Eva
luat
e ou
tcom
es o
f se
vere
obe
sity
(B
MI ≥
40 k
g/m
2 )
60-d
ay M
orta
lity
:●
BM
I 25
-29.
9 vs
nor
mal
BM
I, O
R 0
.81
(95%
CI,
0.
71-0
.91)
, P <
.001
● B
MI
30-3
9.9
vs n
orm
al B
MI,
OR
0.7
4 (9
5% C
I,
0.64
-0.8
4, P
< .0
01)
● B
MI ≥
40 v
s no
rmal
BM
I, O
R 0
.87
(95%
CI,
0.
69-1
.09)
Ven
tila
tor
Day
s:●
BM
I 25
-29.
9 vs
nor
mal
BM
I, H
R (
low
haz
ard
rati
o in
this
stu
dy in
dica
tes
high
er r
isk)
0.9
7 (9
5%
CI,
0.9
-1.0
5)●
BM
I 30
-39.
9 vs
nor
mal
BM
I, H
R 0
.85
(95%
CI,
0.
78-0
.93,
P <
.001
)●
BM
I ≥
40 v
s no
rmal
BM
I, H
R 0
.86
(95%
CI,
0.
77-0
.97,
P <
.05)
ICU
LO
S:
● B
MI
25-2
9.9
vs n
orm
al B
MI,
HR
0.9
5 (9
5% C
I,
0.88
-1.0
3)●
BM
I 30
-39.
9 vs
nor
mal
BM
I, H
R 0
.86
(95%
CI,
0.
79-0
.94,
P <
.001
)●
BM
I ≥
40 v
s no
rmal
BM
I, H
R 0
.82
(95%
CI,
0.
72-0
.93,
P <
.05)
Hos
pit
al L
OS
:●
BM
I 25
-29.
9 vs
nor
mal
BM
I, H
R 0
.98
(95%
CI,
0.
91-1
.05)
● B
MI
30-3
9.9
vs n
orm
al B
MI,
HR
0.9
6 (9
5% C
I,
0.89
-1.0
4)●
BM
I ≥
40 v
s no
rmal
BM
I, H
R 0
.91
(95%
CI,
0.
80-1
.04)
Obe
se p
atie
nts
(BM
I 30
-39.
9) w
ith
low
er
mor
tali
ty; a
ll o
bese
pa
tien
ts w
ith
long
er
vent
ilat
or in
tuba
tion
and
IC
U L
OS
Ser
rano
et a
l, 20
1025
Ret
rosp
ecti
ve r
ecor
d re
view
314
obes
e pa
tien
tsO
R a
djus
ted
for
pote
ntia
l co
nfou
nder
s
Adm
issi
ons
to le
vel I
trau
ma
cent
er 2
008
● B
MI
18.5
-24.
9, n
= 3
82●
BM
I 25
-29.
9, n
= 3
28●
BM
I 30
-39.
9, n
= 2
50●
BM
I ≥
40, n
= 6
4T
otal
N =
102
4
Eva
luat
e th
e im
port
ance
of
obe
sity
as
an
inde
pend
ent r
isk
fact
or
for
noso
com
ial i
nfec
tion
in
trau
ma
pati
ents
Infe
ctio
n:
● B
MI
30-3
9.9
vs n
orm
al B
MI,
OR
4.6
9 (9
5% C
I,
2.18
-10.
1)●
BM
I ≥
40 v
s no
rmal
BM
I, O
R 5
.91
(95%
CI,
2.
18-1
6.0)
Mos
t com
mon
type
s w
ere
pulm
onar
y an
d w
ound
in
fect
ions
Obe
sity
is in
depe
nden
t ris
k fa
ctor
for
infe
ctio
n af
ter
trau
ma
(con
tinu
ed)
Tab
le 2
. (c
onti
nu
ed)
719
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Wur
zing
er e
t al,
2010
26R
etro
spec
tive
rec
ord
revi
ew66
obe
se p
atie
nts,
no
pow
er
calc
ulat
ion
● B
MI ≤
18.5
kg/
m2 , n
= 1
5●
BM
I 18
.5-2
4.9,
n =
125
● B
MI
25-2
9.9,
n =
95
● B
MI
30-3
9.9,
n =
66
Tot
al N
= 3
01
Eva
luat
e im
pact
of
BM
I on
mor
tali
ty in
pat
ient
s w
ith
sept
ic s
hock
In a
djus
ted
mod
el, n
o di
ffer
ence
in m
orta
lity
by
obes
ity
SA
PS
II
pred
icts
mor
tali
ty
Duc
hesn
e et
al,
2009
48R
etro
spec
tive
rec
ord
revi
ewV
ery
smal
l sam
ple
52 o
bese
pat
ient
s
All
pat
ient
s in
Lev
el I
trau
ma
cent
er 2
003-
2006
, tot
al
sam
ple
12,7
59 p
atie
nts
Tho
se w
ith
dam
age
cont
rol
lapa
roto
my:
● B
MI ≤
18.5
-29.
9 kg
/m2 , n
=
52●
BM
I 30
-39.
9, n
= 3
8●
BM
I ≥
40, n
= 1
5T
otal
N =
105
Exa
min
e pr
eval
ence
of
surg
ical
sit
e in
fect
ions
in
obe
se v
s no
nobe
se
pati
ents
Su
rgic
al S
ite
Infe
ctio
ns:
● P
reva
lenc
e ra
tio
in B
MI ≥
40 v
s no
nobe
se 4
.42
(95%
CI,
1.7
4-11
.2)
Intr
aab
dom
inal
Ab
sces
s:●
Pre
vale
nce
rati
o in
BM
I ≥
40 v
s no
nobe
se 1
.76
(95%
CI,
0.7
3-4.
28)
Acu
te R
enal
In
jury
:●
Pre
vale
nce
rati
o in
BM
I 30
-39.
9 vs
non
obes
e 2.
07(9
5% C
I, 1
.9-4
.7)
● P
reva
lenc
e ra
tio
in B
MI ≥
40 v
s no
nobe
se 3
.07
(95%
CI,
1.3
4-7.
03)
Mu
ltis
yste
m O
rgan
Fai
lure
:●
Pre
vale
nce
rati
o in
BM
I 30
-39.
9 vs
non
obes
e 1.
74 (
95%
CI,
1.1
4-2.
66)
● P
reva
lenc
e ra
tio
in B
MI ≥
40 v
s no
nobe
se 1
.82
(95%
CI,
1.1
4-2.
90)
Pre
vale
nce
rati
os a
djus
ted
for
age,
gen
der,
type
of
inju
ry, b
lood
pre
ssur
e an
d ba
se d
efic
itD
ays
on V
enti
lato
r:●
Non
obes
e vs
obe
se v
s se
vere
ly o
bese
, 9.8
± 7
vs
14 ±
7 v
s 24
± 8
, P =
.000
1H
osp
ital
LO
S:
● N
onob
ese
vs o
bese
vs
seve
rely
obe
se, 1
4 ±
8 vs
14
± 1
1 vs
27
± 9,
P =
.000
1
Dos
sett
et a
l, 20
0947
Pro
spec
tive
coh
ort o
bser
vati
onO
R a
djus
ted
for
age,
sex
, A
PA
CH
E I
I sc
ore
686
obes
e pa
tien
ts
Pat
ient
s in
IC
U >
48
hr●
BM
I ≤
18.5
kg/
m2 , n
= 6
40●
BM
I 18
.5-2
4.9,
n =
672
● B
MI
25-2
9.9,
n =
615
● B
MI
30-3
9.9,
n =
494
● B
MI ≥
40, n
= 1
92T
otal
N =
203
7
Des
crib
e re
lati
onsh
ip
betw
een
BM
I an
d si
te-
spec
ific
IC
U-a
cqui
red
infe
ctio
n ri
sk
● C
ath
eter
-rel
ated
Blo
odst
ream
In
fect
ion
Ris
k:
● B
MI
30-3
9.9
vs n
orm
al B
MI,
OR
1.9
(95
% C
I,
1.2-
2.9)
● B
MI ≥
40 v
s no
rmal
BM
I, O
R 3
.2 (
95%
CI,
1.9
-5.
3)
May
be
due
to p
rovi
der
relu
ctan
ce to
pul
l es
tabl
ishe
d li
nes
in
pati
ents
wit
h di
ffic
ult
veno
us a
cces
s
Pie
racc
i et a
l, 20
0827
Ret
rosp
ecti
ve r
ecor
d re
view
BM
I di
stri
buti
on o
f pa
tien
ts in
IC
U >
4 d
ays
not c
lear
232
obes
e pa
tien
ts
Pat
ient
s ad
mit
ted
to I
CU
> 4
da
ys●
BM
I ≤
18.5
kg/
m2 , n
= 5
3●
BM
I 18
.5-2
4.9,
n =
376
● B
MI
25-2
9.9,
n =
285
● B
MI
30-3
9.9,
n =
188
● B
MI ≥
40, n
= 4
4T
otal
N =
946
Tes
t hyp
othe
sis
that
BM
I is
ass
ocia
ted
wit
h m
orta
lity
fro
m s
urgi
cal
crit
ical
illn
ess
RO
C a
naly
sis
sugg
ests
BM
I pr
edic
ts m
orta
lity
at
leve
l of
chan
ce a
lone
Age
and
AP
AC
HE
III
wer
e st
rong
est p
redi
ctor
s in
al
l mod
els,
BM
I w
as n
ot s
igni
fica
nt
Tab
le 2
. (c
onti
nu
ed)
(con
tinu
ed)
720
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Sak
r et
al,
2008
46P
rosp
ecti
ve o
bser
vati
onal
coh
ort
505
obes
e pa
tien
tsA
djus
ted
mod
el
Mul
tice
nter
stu
dy o
f ep
idem
iolo
gy o
f se
psis
in
Eur
opea
n co
untr
ies,
n =
198
IC
Us
● B
MI ≤
18.5
kg/
m2 , n
= 1
20●
BM
I 18
.5-2
4.9,
n =
120
6●
BM
I 25
-29.
9, n
= 1
047
● B
MI
30-3
9.9,
n =
424
● B
MI ≥
40, n
= 8
1T
otal
N =
287
8
Inve
stig
ate
impa
ct o
f ob
esit
y on
mor
bidi
ty
and
mor
tali
ty in
E
urop
ean
seps
is in
ac
utel
y il
l pat
ient
s st
udy
BM
I do
es n
ot im
pact
mor
tali
ty o
r L
OS
ICU
-acq
uir
ed I
nfe
ctio
n:
● O
bese
vs
opti
mal
wei
ght,
10.1
% v
s 9%
, P <
.05
● S
ever
ely
obes
e vs
opt
imal
wei
ght,
12.3
% v
s 9.
0%, P
< .0
1
Fra
t et a
l, 20
0836
Pro
spec
tive
cas
e-co
ntro
l ob
serv
atio
n82
obe
se p
atie
nts
Pro
gnos
tic
sim
ilar
ity
Pat
ient
s m
atch
ed f
or a
ge, g
ende
r,
cent
er a
nd S
AP
S I
I sc
ore
● B
MI
< 3
0, n
= 1
24●
BM
I ≥
35, n
= 8
2T
otal
N =
206
Eva
luat
e in
flue
nce
of
seve
re o
besi
ty o
n m
orbi
dity
and
mor
tali
ty
in m
echa
nica
lly
vent
ilat
ed p
atie
nts
Onl
y di
ffer
ence
in m
orbi
dity
was
mor
e fr
eque
nt
diff
icul
ty w
ith
trac
heal
intu
bati
on a
nd
post
extu
bati
on s
trid
or in
obe
seN
o di
ffer
ence
in m
orta
lity
Mor
ris
et a
l, 20
0728
Ret
rosp
ecti
ve r
ecor
d re
view
165
obes
e pa
tien
tsO
R a
djus
ted
for
age,
AP
AC
HE
sc
ore,
adm
issi
on s
ourc
e,
chro
nic
heal
th p
oint
s, e
tiol
ogy
of A
LI
All
IC
U p
atie
nts
wit
h A
LI
and
BM
I in
199
9-20
00●
BM
I <
18.
5 kg
/m2 , n
= 2
8●
BM
I 18
.5-2
4.9,
n =
179
● B
MI
25-2
9.9,
n =
150
● B
MI
30-3
9, n
= 1
25●
BM
I ≥
40, n
= 4
0T
otal
N =
825
Eva
luat
e th
e as
soci
atio
n be
twee
n B
MI
and
outc
omes
in p
atie
nts
wit
h A
LI
Mor
tali
ty:
● N
ot d
iffe
rent
by
BM
I gr
oup
Dis
char
ge D
isp
osit
ion
:●
To
reha
bili
tati
on c
ente
r B
MI ≥
40 v
s no
rmal
B
MI,
OR
6.0
(95
% C
I, 1
.8-2
0.2)
To
skil
led
nurs
ing
faci
lity
BM
I ≥
40 v
s no
rmal
B
MI,
OR
4.3
(95
% C
I, 1
.5-1
2.5)
New
ell e
t al,
2007
37R
etro
spec
tive
rec
ord
revi
ew26
4 ob
ese
pati
ents
, no
pow
er
stat
emen
tN
o ad
just
men
t of
OR
Con
secu
tive
adm
issi
ons
to
trau
ma
cent
er w
ith
Inju
ry
Sev
erit
y S
core
≥ 1
6 an
d bl
unt
trau
ma
in 2
001-
2005
● B
MI
mis
sing
n =
357
● B
MI
< 1
8.5
kg/m
2 , n =
61
● B
MI
18.5
-24.
9, n
= 5
54●
BM
I 25
-29.
9, n
= 5
29●
BM
I 30
-39,
n =
271
● B
MI ≥
40, n
= 9
3T
otal
N =
210
8
Eva
luat
e cl
inic
al o
utco
mes
in
blu
nt tr
aum
a pa
tien
ts
stra
tifi
ed b
y B
MI
Mor
tali
ty:
BM
I ≥
40 v
s no
rmal
BM
I, O
R 0
.81
(95%
CI,
0.3
5-1.
86)
Com
pli
cati
ons
in B
MI
30-3
9.9
vs n
orm
al B
MI:
● A
cute
res
pira
tory
fai
lure
, OR
1.8
(95
% C
I, 1
.3-
2.4)
● P
neum
onia
, OR
1.7
(95
% C
I, 1
.2-2
.4)
● U
TI,
OR
1.8
(95
% C
I, 1
.2-2
.9)
Com
pli
cati
ons
in B
MI ≥
40 v
s n
orm
al B
MI:
● A
RD
S, O
R 3
.68
(95%
CI,
1.2
-10.
9)●
Acu
te r
espi
rato
ry f
ailu
re, O
R 2
.79
(95%
CI,
1.6
-4.
8)●
Acu
te r
enal
fai
lure
, OR
13.
5 (9
5% C
I, 2
.4-7
6.4)
● M
SO
F, O
R 2
.6 (
95%
CI,
1.0
9-6.
4)●
Pne
umon
ia, O
R 2
.5 (
95%
CI,
1.5
-4.3
)●
UT
I, O
R 2
.3 (
95%
CI,
1.2
-4.4
)●
DV
T, O
R 4
.1 (
95%
CI,
1.3
-13.
5)D
ecub
itus
ulc
er, O
R 2
.8 (
95%
CI,
1.4
-5.8
)
Com
plic
atio
ns h
ighe
r in
se
vere
ly o
bese
than
obe
se
than
nor
mal
BM
I pa
tien
ts
Tab
le 2
. (c
onti
nu
ed)
(con
tinu
ed)
721
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Nas
raw
ay e
t al,
2006
90R
etro
spec
tive
rec
ord
revi
ew96
obe
se p
atie
nts
mod
el a
djus
ted
for
age,
gen
der,
ac
uity
, ren
al f
ailu
re, d
iabe
tes,
va
sopr
esso
r us
e, m
echa
nica
l ve
ntil
atio
n
Con
secu
tive
adm
issi
ons
to
surg
ical
IC
U 1
998-
2001
● B
MI ≤
18.5
kg/
m2 , n
= 7
0●
BM
I 18
.5-2
4.9,
n =
529
● B
MI
25-2
9.9,
n =
408
● B
MI
30-3
9.9,
n =
272
● B
MI ≥
40, n
= 9
4T
otal
N =
137
3P
atie
nts
who
sta
yed
in I
CU
≥ 4
d●
BM
I ≤
18.5
kg/
m2 , n
= 2
6●
BM
I 18
.5-2
4.9,
n =
164
● B
MI
25-2
9.9,
n =
119
● B
MI
30-3
9.9,
n =
74
● B
MI ≥
40, n
= 2
4T
otal
N =
406
Det
erm
ine
whe
ther
BM
I ≥
40 is
inde
pend
ent r
isk
fact
or f
or d
eath
in I
CU
pa
tien
ts
Mor
tali
ty, I
CU
LO
S a
nd h
ospi
tal L
OS
not
dif
fere
nt
in e
ntir
e gr
oup
of a
dmis
sion
s
Pea
ke e
t al,
2006
38P
rosp
ecti
ve c
ohor
t obs
erva
tion
125
obes
e pa
tien
tsM
odel
incl
uded
age
, AP
AC
HE
II
sco
re, a
lbum
in C
harl
son
com
orbi
dity
inde
x
Pat
ient
s ad
mit
ted
to m
edic
al-
surg
ical
IC
U in
200
1●
BM
I <
18.
5 kg
/m2 , n
= 2
4●
BM
I 18
.5-2
4.9,
n =
129
● B
MI
25-2
9.9,
n =
151
● B
MI
30-3
4.9,
n =
75
● B
MI ≥
35, n
= 5
4T
otal
N =
433
Eva
luat
e ef
fect
of
BM
I on
30
-day
and
12-
mon
th
surv
ival
Incr
easi
ng B
MI
asso
ciat
ed w
ith
decr
easi
ng
mor
tali
tyT
R >
1 is
incr
ease
d su
rviv
al ti
me:
● 3
0-da
y T
R f
or B
MI
= 1
.85
(95%
CI,
1.0
5, 3
.26)
12-m
onth
TR
for
BM
I =
1.0
3 (9
5% C
I, 1
.005
, 1.
063)
Dua
ne e
t al,
2006
39R
etro
spec
tive
rec
ord
revi
ew11
5 ob
ese
pati
ents
, no
pow
er
stat
emen
t
Blu
nt tr
aum
a pa
tien
ts a
dmit
ted
2004
-200
5●
BM
I <
30,
n =
338
● B
MI ≥
30, n
= 1
15T
otal
N =
453
Det
erm
ine
effe
ct o
f ob
esit
y on
mor
bidi
ty
and
mor
tali
ty in
IC
U
and
non-
ICU
pop
ulat
ion
of b
lunt
trau
ma
pati
ents
No
diff
eren
ce in
mor
tali
ty o
r m
orbi
dity
mea
sure
s
Alb
an e
t al,
2006
40R
etro
spec
tive
rec
ord
revi
ew13
5 ob
ese
pati
ents
, no
pow
er
stat
emen
t
Pat
ient
s ad
mit
ted
to tr
aum
a IC
U,
1999
-200
2N
onob
ese,
n =
783
Obe
se, n
= 1
35T
otal
, n =
928
Com
pare
out
com
es o
f ob
ese
vs n
onob
ese
pati
ents
aft
er tr
aum
a
Mor
tali
ty:
● O
bese
vs
nono
bese
, OR
0.8
(95
% C
I, 0
.3-1
.8)
● A
ge >
55
y, O
R 3
.5 (
95%
CI,
1.8
-6.6
)●
IS
S >
20,
OR
8.9
(95
% C
I, 4
.2-1
8.8)
● A
PA
CH
E I
I >
20,
OR
12.
0 (9
5% C
I,4.
7-30
.6)
● B
lunt
vs
pene
trat
ing
inju
ry, O
R 2
.0 (
95%
CI,
1.1
-3.
9)
Sev
erit
y of
illn
ess
mor
e pr
edic
tive
than
obe
sity
O’B
rien
et a
l, 20
0642
Ret
rosp
ecti
ve r
ecor
d re
view
457
obes
e pa
tien
tsM
orta
lity
adj
uste
d fo
r ag
e,
gend
er, r
ace,
SA
PS
II,
te
am m
odel
, con
diti
on
on a
dmis
sion
, pat
ient
or
igin
, dia
gnos
is o
f sk
in o
r su
bcut
aneo
us ti
ssue
dis
ease
, pr
eexi
stin
g il
lnes
s, u
se o
f pr
esso
rs, I
CU
com
plic
atio
ns,
num
ber
of p
reex
isti
ng
dise
ases
Cri
tica
lly
ill a
dult
s fr
om 1
06
ICU
s in
84
hosp
ital
s in
acu
te
lung
inju
ry I
MP
AC
T s
tudy
● B
MI
< 1
8.5
kg/m
2, n
= 8
8●
BM
I 18
.5-2
4.9,
n =
544
● B
MI
25-2
9.9,
n =
399
● B
MI
30-3
9.9,
n =
326
● B
MI ≥
40, n
= 1
31T
otal
N =
148
8
Det
erm
ine
asso
ciat
ion
betw
een
BM
I an
d ho
spit
al m
orta
lity
Hos
pit
al M
orta
lity
:●
BM
I 30
-39.
9 vs
nor
mal
BM
I, O
R 0
.67
(95%
CI,
0.
46-0
.97)
● B
MI ≥
40 v
s no
rmal
BM
I, O
R 0
.78
(95%
CI,
0.
44-1
.38)
Un
adju
sted
Dif
fere
nce
s in
Car
e:●
BM
I ≥
40 v
s no
rmal
BM
I●
Hep
arin
pro
phyl
axis
in 5
7% v
s 44
%●
Tra
cheo
stom
y, 2
6% v
s 17
%●
Spe
cial
ty b
ed, 2
9% v
s 15
%
Tab
le 2
. (c
onti
nu
ed)
(con
tinu
ed)
722
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Ald
awoo
d et
al,
2006
35R
etro
spec
tive
rec
ord
revi
ew54
0 ob
ese
pati
ents
Una
djus
ted
OR
Cri
tica
lly
ill a
dult
s fr
om s
ingl
e IC
U in
Sau
di A
rabi
a, 2
001-
2004
● B
MI
< 1
8.5k
g/m
2 , n =
140
● B
MI
18.5
-24.
9, n
= 6
31●
BM
I 25
-29.
9, n
= 5
24●
BM
I 30
-34.
9, n
= 3
12●
BM
I 35
-39.
9, n
= 1
35●
BM
I ≥
40, n
= 9
3T
otal
N =
183
5
Exa
min
e im
pact
of
obes
ity
on h
ospi
tal a
nd
ICU
mor
tali
ty, L
OS
, du
rati
on o
f m
echa
nica
l ve
ntil
atio
n
Hos
pit
al M
orta
lity
:●
BM
I ≥
40 v
s no
rmal
BM
I, O
R 0
.51
(95%
CI,
0.
28-0
.92,
P =
.025
)A
lso
pred
icte
d by
chr
onic
res
pira
tory
illn
ess,
age
, m
edic
al v
s su
rgic
al a
dmis
sion
Low
est m
orta
lity
for
BM
I ≥
40
Ray
et a
l, 20
0532
Ret
rosp
ecti
ve r
ecor
d re
view
550
obes
e pa
tien
tsN
o ad
just
men
t for
acu
ity
Med
ical
IC
U a
dmis
sion
s 19
97-
2001
● B
MI
< 2
0 kg
/m2,
n =
350
● B
MI
20-2
4.9,
n =
663
● B
MI
25-2
9.9,
n =
585
● B
MI
30-3
9.9,
n =
396
● B
MI ≥
40, n
= 1
54T
otal
N =
214
8
Exa
min
e th
e ef
fect
of
BM
I on
IC
U o
utco
me
ICU
Mor
tali
ty:
AP
AC
HE
II
scor
e pr
edic
ts (
P <
.001
) bu
t BM
I do
es
not (
P =
.588
)H
osp
ital
Mor
tali
ty:
AP
AC
HE
II
scor
e pr
edic
ts (
P <
.001
) bu
t BM
I do
es
not (
P =
.469
)C
omp
lica
tion
s:N
o di
ffer
ence
by
BM
I gr
oup
Acu
ity
scor
e pr
edic
ts
mor
tali
ty b
ette
r th
an B
MI
Win
kelm
an e
t al
, 200
541P
rosp
ecti
ve c
ohor
t obs
erva
tion
Sm
all s
ampl
eC
riti
call
y il
l pat
ient
s w
ith
seve
re
obes
ity
BM
I ≥
40, n
= 4
3
Des
crib
e re
sour
ces
used
by
nur
ses
to c
are
of
pati
ents
wit
h se
vere
ob
esit
y
Mos
t co
mm
on e
qu
ipm
ent:
Spe
cial
ty b
ed o
r m
attr
ess
Lar
ge B
P c
uff
Lar
ge c
omm
odes
Lar
ge w
heel
chai
rsA
ssis
t of
2 to
rep
osit
ion
pati
ent
Spe
cial
ski
n ca
re tr
eatm
ent
Nur
ses
shou
ld a
ntic
ipat
e th
ese
need
s to
avo
id p
oor
outc
omes
Bro
wn
et a
l, 20
0533
Ret
rosp
ecti
ve r
ecor
d re
view
283
obes
e pa
tien
tsO
R a
djus
ted
but f
acto
rs u
sed
not
repo
rted
Tra
uma
and
ICU
dat
abas
e●
BM
I <
30,
n =
870
● B
MI ≥
30, n
= 2
83T
otal
N =
115
3
Eva
luat
e in
flue
nce
of
obes
ity
on o
utco
mes
af
ter
seve
re b
lunt
tr
aum
a
Obe
sity
inde
pend
ent r
isk
fact
or f
or m
orta
lity
:A
dj O
R 1
.6 (
95%
CI,
1.0
- 2.
3, P
= .0
3)IS
S, G
CS
, hyp
oten
sion
on
adm
issi
on a
nd a
ge a
re
stro
nger
pre
dict
ors
Obe
se p
atie
nts
wit
h m
ore
tota
l com
plic
atio
ns,
MS
OF
, AR
DS
, dia
lysi
s, M
I
O’B
rien
, 200
434R
etro
spec
tive
rec
ord
revi
ew21
9 ob
ese
pati
ents
, no
pow
er
stat
emen
t15
% e
xclu
ded
due
to m
issi
ng
vari
able
sM
odel
not
adj
uste
d
Mec
hani
call
y ve
ntil
ated
pat
ient
s w
ith
AL
I en
roll
ed in
RC
T
test
ing
wea
ning
pro
toco
ls●
BM
I 18
.5-2
4.9,
n =
334
● B
MI
25-2
9.9,
n =
254
● B
MI ≥
30, n
= 2
19T
otal
N =
807
Exa
min
e as
soci
atio
n of
ob
esit
y an
d ou
tcom
e28
-day
Mor
tali
ty:
● O
verw
eigh
t vs
norm
al B
MI,
OR
1.0
9 (9
5% C
I,
0.7-
1.7)
● O
bese
vs
norm
al B
MI,
OR
1.1
(95
% C
I, 0
.7-1
.8)
● A
ge, O
R 1
.04
(95%
CI,
1.0
3-1.
06)
● A
PA
CH
E I
II s
core
, OR
1.0
2 (9
5% C
I, 1
.01-
1.03
)●
Pao
2:F
iox
rati
o, O
R 0
.99
(95%
CI,
0.9
9-0.
99)
● A
ssig
ned
high
er ti
dal v
olum
e, O
R 1
.7 (
95%
CI,
1.
2-2.
4)●
Pea
k ai
rway
pre
ssur
e, O
R 1
.03
(95%
CI,
1.0
-1.
05)
● T
raum
a di
agno
sis,
OR
0.3
2 (9
5% C
I, 0
.12-
086)
Acu
ity
fact
ors
mor
e im
port
ant t
han
BM
I as
pr
edic
tors
of
outc
ome
Tab
le 2
. (c
onti
nu
ed)
(con
tinu
ed)
723
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Gar
rous
te-
Org
eas
et a
l, 20
0443
Pro
spec
tive
coh
ort o
bser
vati
on22
7 ob
ese
pati
ents
In 6
med
ical
-sur
gica
l IC
Us
in
Fra
nce
over
2 y
ears
● B
MI
< 1
8.5,
n =
189
● B
MI
18.5
-24.
9, n
= 8
06●
BM
I 25
-29.
9, n
= 4
76●
BM
I ≥
30, n
= 2
27T
otal
N =
169
8
Exa
min
e as
soci
atio
n be
twee
n B
MI
and
mor
tali
ty in
adu
lt I
CU
pa
tien
ts
Mor
tali
ty:
Obe
se v
s no
rmal
BM
I, O
R 0
.6 (
95%
CI,
0.4
-0.8
8)
Tre
mbl
ay e
t al,
2003
29R
etro
spec
tive
rec
ord
revi
ew18
,221
obe
se p
atie
nts
Lim
ited
info
rmat
ion
on
com
orbi
d co
ndit
ions
Proj
ect I
mpa
ct C
ritic
al C
are
Dat
a Sy
stem
, all
patie
nts
with
BM
I an
d at
leas
t 1 s
ever
ity s
core
● B
MI
< 1
8.5,
n =
11,
479
● B
MI
18.5
-24.
9, n
= 2
4,33
2●
BM
I 25
-29.
9, n
= 2
1,86
7●
BM
I 30
-39.
9, n
= 1
3,95
2●
BM
I ≥
40, n
= 4
269
Tot
al N
= 7
5,88
9
Mor
tali
ty:
● N
ot s
igni
fica
ntly
dif
fere
nt in
obe
se o
r se
vere
ly
obes
e fr
om n
onob
ese
LO
S:
● N
ot s
igni
fica
ntly
dif
fere
nt in
obe
se o
r se
vere
ly
obes
e fr
om n
onob
ese
Hos
pit
aliz
ed n
on-I
CU
pat
ien
ts
Naf
iu e
t al,
2012
30R
etro
spec
tive
rec
ord
revi
ew49
,761
obe
se p
atie
nts
Mod
el a
djus
ted
for
age,
an
esth
esia
sta
tus,
rac
ial g
roup
, el
ecti
ve v
s em
erge
nt s
urge
ry
Rac
ial/
ethn
ic m
inor
ity
surg
ical
pa
tien
ts 2
005-
2008
fro
m 1
86
cent
ers
in N
atio
nal S
urgi
cal
Qua
lity
Im
prov
emen
t Pro
gram
● O
vera
ll B
MI
= 3
0.3
± 8.
9 kg
/m
2
● B
MI
< 1
8.5
kg/m
2 , n =
323
0●
BM
I =
18.
6-24
.9, n
= 3
1,69
9●
BM
I 25
.0-2
9.9,
n =
34,
929
● B
MI
= 3
0-39
.9, n
= 3
4,45
0●
BM
I ≥
40, n
= 1
5,31
1T
otal
N =
119
,619
Eva
luat
e co
ntri
buti
on
of B
MI
to 3
0-da
y po
stsu
rgic
al o
utco
me
30-d
ay M
orta
lity
:●
BM
I 18
.6-2
4.9
vs B
MI ≥
40, O
R 1
.52
(95%
CI,
1.
23-1
.87,
P <
.001
)●
BM
I 25
.0-2
9.9
vs B
MI ≥
40, O
R 1
.33
(95%
C
I,1.
08-1
.65,
P =
.009
)●
BM
I =
30-
39.9
vs
BM
I ≥
40, O
R 1
.2 (
95%
CI,
0.
97-1
.49)
Hos
pit
al L
OS
:●
BM
I 18
.6-2
4.9,
8.9
± 1
4.2
d●
BM
I 25
.0-2
9., 7
.3 ±
12.
2, P
< .0
01 v
s no
rmal
BM
I●
BM
I = 3
0-39
.9, 6
.7 ±
11.
6, P
< .0
01 v
s no
rmal
BM
I●
BM
I ≥
40, 5
.3 ±
10.
5, P
< .0
01 v
s no
rmal
BM
I●
Mos
t per
iope
rati
ve o
utco
mes
in o
bese
sub
ject
s no
t dif
fere
nt th
an n
orm
al w
eigh
t
BM
I ≥
40 w
ith
low
est
mor
tali
ty &
hos
pita
l L
OS
.A
utho
rs s
ugge
st th
at o
bese
pa
tien
ts m
ay h
ave
less
se
vere
dis
ease
or
that
th
ey a
re m
onit
ored
vi
gila
ntly
and
trea
ted
cons
erva
tive
ly
Das
et a
l, 20
1149
Ret
rosp
ecti
ve r
ecor
d re
view
OR
adj
uste
d fo
r ag
e, p
rior
PA
D,
BP
, HR
, sho
ck, E
CG
fin
ding
s,
trop
onin
rat
io, c
reat
inin
e25
58 p
atie
nts
wit
h se
vere
obe
sity
Pat
ient
s in
the
Nat
iona
l C
ardi
ovas
cula
r D
ata
Reg
istr
y w
ith
diag
nosi
s of
MI
● B
MI
mis
sing
in 1
831
(3.5
%)
● B
MI ≤
18.5
kg/
m2 , n
= 3
44●
BM
I 18
.5-2
4.9,
n =
11,
785
● B
MI
25-2
9.9,
n =
19,
408
● B
MI
30-3
9.9,
n =
15,
596
● B
MI ≥
40, n
= 2
558
Tot
al N
= 5
0,14
9
Eva
luat
e im
pact
of
seve
re
obes
ity
on o
utco
mes
in
pat
ient
s w
ith
ST
-se
gmen
t MI
Mor
tali
ty:
● B
MI ≥
40 v
s B
MI
30-3
5, A
djus
ted
OR
1.6
4 (9
5%
CI,
1.3
2-2.
03)
Maj
or B
leed
ing:
BM
I ≥
40 v
s B
MI
30-3
5, A
djus
ted
OR
1.0
9 (9
5%
CI,
0.9
4-1.
26)
Mor
tali
ty in
crea
sed
Par
k et
al,
2011
31R
etro
spec
tive
rec
ord
revi
ewN
o ac
uity
sco
res
No
adju
stm
ent f
or c
onfo
unde
rs14
7 ob
ese
pati
ents
Sur
gica
l pat
ient
s fr
om s
ingl
e ho
spit
al 1
999-
2009
● B
MI
18.5
-24.
9, n
= 4
69●
BM
I 30
-39.
9, n
= 1
08●
BM
I ≥
40, n
= 3
9T
otal
N =
626
Det
erm
ine
impa
ct o
f obe
sity
on
per
iope
rativ
e an
d lo
ng-
term
clin
ical
out
com
es
afte
r ope
n A
AA
repa
ir o
r en
dova
scul
ar a
neur
ysm
re
pair
No
diff
eren
ce in
LO
S, M
I, A
RF
, wou
nd in
fect
ion,
m
orta
lity
ICU
LO
S:
Obe
se v
s no
rmal
BM
I, P
= .0
3
Low
HR
indi
cate
s in
crea
sed
risk
; low
OR
indi
cate
s re
duce
d ri
sk. A
AA
, abd
omin
al a
orti
c an
eury
sm; A
LI,
acu
te lu
ng in
jury
; AP
AC
HE
, Acu
te P
hysi
olog
y an
d C
hron
ic H
ealt
h; A
RD
S, a
cute
res
pira
tory
di
stre
ss s
yndr
ome;
AR
F, a
cute
ren
al f
ailu
re; B
MI,
bod
y m
ass
inde
x; B
P, b
lood
pre
ssur
e; C
CU
, car
diac
car
e un
it; C
I, c
onfi
denc
e in
terv
al; D
VT
, dee
p ve
in th
rom
bosi
s; G
CS
, Gla
sgow
com
a sc
ale;
HR
, ha
zard
rat
io; I
CU
, int
ensi
ve c
are
unit
; IS
S, i
njur
y se
veri
ty s
core
; LO
S, l
engt
h of
sta
y; M
I, m
yoca
rdia
l inf
arct
ion;
MIC
U, m
edic
al I
CU
; MS
OF
, mul
ti-s
yste
m o
rgan
fai
lure
; OR
, odd
s ra
tio;
PA
D, p
erip
h-er
al a
rter
y di
seas
e; R
CT
, ran
dom
ized
con
trol
led
tria
l; R
OC
, rec
eive
r op
erat
or c
urve
; SA
PS
, sim
plif
ied
acut
e ph
ysio
logy
sco
re; S
ICU
, sur
gica
l IC
U; T
R, t
ime
rati
o; U
TI,
uri
nary
trac
t inf
ecti
on.
Tab
le 2
. (c
onti
nu
ed)
724 Journal of Parenteral and Enteral Nutrition 37(6)
Table 3. GRADE Table Question 1: Do Clinical Outcomes Vary Across Levels of Obesity in Critically Ill or Hospitalized Non-ICU Patients?
Comparison OutcomeQuantity, Type
of Evidence FindingsGrade for Outcome
Overall Evidence GRADE
ICU patients
Obese vs optimal BMI Mortality (large studies) 8 OBS 1 increased21
5 decreased23,35,42,44,45
2 no difference32,46
Low Low
Hospital LOS (large studies) 4 OBS 3 increased22,29,45
1 no difference46Low
Complications 6 OBS 5 increased25,37,46-48
1 no difference32Low
BMI ≥ 40 kg/m2 vs optimal BMI Mortality (large studies) 4 OBS 1 decreased44
3 no difference22,23,45Low
Hospital LOS (large studies) 4 OBS 2 increased22,29
2 no difference45,46Low
Non-ICU patients
Obese vs optimal BMI Mortality 2 OBS 1 increased49
1 no difference91Low
ICU, intensive care unit; LOS, length of stay; OBS, observational study.
would be especially helpful. Finally, nutrition support inter-ventions that aim to improve clinical outcomes are needed in this population.
Question 2: How Should Energy Requirements Be Determined in Obese Critically Ill or Hospitalized Non-ICU Patients? (Table 4)
Recommendation2a. In the critically ill obese patient, if indirect calorimetry
is unavailable, energy requirements should be based on the Penn State University 2010 predictive equation or the modi-fied Penn State University equation if the patient is over the age of 60 years (strong).Evidence Grade: High.
2b. In the hospitalized obese patient, if indirect calorimetry is unavailable and the Penn State University equations cannot be used, energy requirements may be based on the Mifflin–St Jeor equation using actual body weight (weak).Evidence Grade: Moderate.
Rationale. Most studies recommend the use of indirect calo-rimetry to measure resting energy expenditure (REE); how-ever, some patients do not meet valid testing criteria, and most facilities do not have indirect calorimeters. Avoiding energy overfeeding is an important goal; therefore either REE or use of a predictive equation to approximate REE is an essential part of nutrition assessment. In the critically ill, ventilator-dependent obese patient, the Penn State University (PSU) predictive equation most accurately predicts REE compared with others (including Harris–Benedict, Mifflin–St
Jeor, Swinamer, and Ireton-Jones). Frankenfield and col-leagues compared multiple predictive equations with REE in patients with BMI ≥ 30 kg/m2 and found the PSU equation to have the highest prediction accuracy of 70% ( ± 10% of REE) with the least bias or the lowest likelihood of over or under-estimation.50 In another comparison study in critically ill patients with BMI ≥ 45 kg/m2, accuracy of the PSU equation was highest at 76% ( ± 10% of REE) compared with other equations studied.51 In the older critically ill obese patient ( ≥ 60 years) with BMI ≥ 30, a modified PSU appears to be more accurate than the original PSU.50 When compared with the unmodified version, the modified PSU was found to have an accuracy rate of 70% ( ± 10% of REE) vs 58% (P = .04).50 Further, in a case series of 7 patients (including 2 obese patients) with REE measured continuously for 7 days, the prediction error using the PSU equation was only a total of –468 ± 642 kcal (–3.7 ± 5.1%) over 1 week.52
The PSU equations53 are as follows:Younger obese patients:
•• RMR (kcal/d) = MSJ(0.96) + Tmax(167) + VE(31) – 6212
Older obese patients:
•• RMR (kcal/d) = MSJ(0.71) + Tmax(85) + VE(64) – 3085
•• ○ Where MSJ = Mifflin–St Jeor equation (below); VE =
minute ventilation (L/minute); Tmax
= maximum tem-perature in prior 24 hours in degrees C
In the mixed ICU and non-ICU patients, the evidence is more difficult to assess due to several important variables. The
725
Tab
le 4
. E
vide
nce
Sum
mar
y Q
uest
ion
2: H
ow S
houl
d E
nerg
y R
equi
rem
ents
Be
Det
erm
ined
in O
bese
Cri
tica
lly
Ill o
r H
ospi
tali
zed
Non
-IC
U P
atie
nts?
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
ICU
pat
ien
ts
Fra
nken
fiel
d et
al,
2012
51V
alid
atio
n st
udy
Sim
ilar
pro
gnos
is in
obe
se
grou
p55
obe
se p
atie
nts
Cri
tica
lly
ill p
atie
nts
at
extr
emes
of
BM
IB
MI ≤
21 k
g/m
2 , n =
56
BM
I ≥
45 k
g/m
2 , n =
55
Val
idat
e th
e P
SU
pre
dict
ion
equa
tion
and
test
val
idit
y of
IJ
, AC
CP
, MS
J, H
B
Acc
ura
cy w
ith
in 1
0% R
EE
(%
):●
PS
U (
76%
)●
MS
J (5
5%)
● H
B (
60%
)●
IJ
(29%
)●
AC
CP
(27
%)
Bia
s in
kca
l/d
(95
% C
I):
● P
SU
(–3
3, +
97)
● M
SJ
(–29
9, –
82)
● H
B (
–105
, +14
9)●
IJ
(+28
3, +
509)
● A
CC
P (
–616
, –40
3)
PS
U v
alid
in s
ever
ely
obes
e,
crit
ical
ly il
l pat
ient
s
Kro
ss e
t al,
2012
92R
etro
spec
tive
val
idat
ion
stud
y40
1 ob
ese
pati
ents
All
mec
hani
call
y ve
ntil
ated
pa
tien
ts w
ith
RE
E b
etw
een
1998
-200
5●
BM
I 18
.5-2
4.9,
n =
254
● B
MI
25-2
9.9,
n =
272
● B
MI
30-3
4.9,
n =
176
● B
MI
35-3
9.9,
n =
84
● B
MI ≥
40, n
= 1
41T
otal
N =
925
Com
pare
RE
E w
ith
HB
, Ow
en,
MS
J, I
J, A
CC
PB
MI
30-3
4.9:
Acc
ura
cy (
%):
● M
SJ
(18.
8%)
● H
B (
34.1
%)
● I
J (2
0.5%
)●
AC
CP
(9.
7%)
● O
wen
(9.
7%)
Bia
s m
ean
(95
% C
I):
● M
SJ,
–17
7.8
(–20
3.9,
–15
1.6)
● H
B, –
53.4
(–7
8.6,
+10
.1)
● I
J, –
86.4
(–1
17.6
, –55
.2)
● A
CC
P, –
218.
7 (–
245.
3, –
192.
2)●
Ow
en, –
205.
6 (–
233.
1, +
177.
9)B
MI
35-3
9.9:
Acc
ura
cy (
%):
● M
SJ
(18.
8%)
● H
B (
27.4
%)
● I
J (2
0.5%
)●
AC
CP
(7.
1%)
● O
wen
(14
.3%
)B
ias
mea
n (
95%
CI)
● M
SJ,
–16
6.6
(–20
9.4,
–12
3.8)
● H
B, –
66.0
(–1
05.1
, +27
.3)
● I
J, –
101.
9 (–
76.7
, +23
.8)
● A
CC
P, –
243.
7 (–
285.
5, –
202.
1)●
Ow
en, –
198.
9 (–
240.
2, –
157)
BM
I ≥
40:
Acc
ura
cy (
%):
● M
SJ
(33.
3%)
● H
B (
28.4
%)
● I
J (1
4.2%
)●
AC
CP
(1.
4%)
● O
wen
(20
.6%
)B
ias
mea
n (
95%
CI)
:●
MS
J, –
91.8
(–1
19.5
, –64
.0)
● H
B, –
61.1
(–5
5.8,
+19
.5)
● I
J, –
91.3
(–1
33.9
, –48
.7)
● A
CC
P, –
243.
7 (–
319.
1, –
261.
4)●
Ow
en, –
145.
2 (–
174.
1, –
116.
3)
Una
ble
to e
valu
ate
PS
U o
r S
win
amer
due
to m
issi
ng
min
ute
vent
ilat
ion
or ti
dal
volu
me
Equ
atio
ns a
re n
ot a
dequ
ate
(con
tinu
ed)
726
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Fra
nken
fiel
d, 2
01153
Val
idat
ion
stud
yIn
clud
ed a
rchi
ved
data
in
ana
lysi
s, u
ncle
ar
prog
nost
ic s
imil
arit
yP
reci
se m
easu
rem
ent
prot
ocol
Obe
se, o
lder
IC
U p
atie
nts,
n
= 5
0A
ge 7
0 ±
7 y
BM
I 38
.4 ±
7.2
kg/
m2
Dat
a fr
om p
revi
ous
stud
ies:
n
= 7
9
Tes
t the
val
idit
y of
a m
odif
ied
PS
U e
quat
ion
agai
nst
Del
tatr
ac R
EE
mea
sure
s
Acc
ura
cy:
● M
odif
ied
PS
U =
70%
● O
rigi
nal P
SU
= 6
6%B
ias
(95%
CI)
:●
Mod
ifie
d P
SU
(–1
20, –
12)
kcal
/d●
Ori
gina
l PS
U (
–90,
+ 2
5) k
cal/
d
Bot
h P
SU
equ
atio
ns in
clud
e bo
th b
ody
size
and
met
abol
ic
fact
ors
(tem
pera
ture
, min
ute
vent
ilat
ion)
Fra
nken
fiel
d et
al,
2009
50V
alid
atio
n st
udy
Sim
ilar
pro
gnos
isR
EE
mea
sure
s in
202
cri
tica
lly
ill p
atie
nts
in 2
006-
2007
:O
bese
you
ng:
n =
47
Obe
se e
lder
ly: n
= 5
1
Com
pare
RE
E m
easu
red
by
Del
tatr
ac c
alor
imet
er w
ith
esti
mat
es b
y H
B, M
SJ,
A
CC
P, S
win
amer
, IJ,
PS
U,
Bra
ndi,
and
Fai
sy e
quat
ions
Acc
ura
cy:
You
ng
Ob
ese:
● P
SU
(66
%)
● M
SJ
(21%
)●
HB
(45
%)
● I
J (4
9%)
● A
CC
P (
53%
)E
lder
ly O
bes
e:●
PS
U (
46%
)●
MS
J (3
5%)
● H
B (
35%
)●
IJ
(51%
)●
AC
CP
(12
%)
Bia
s (9
5% C
I):
You
ng
Ob
ese:
● P
SU
(–2
49, –
31)
● M
SJ
(–54
4, –
316)
● H
B (
–368
, +89
)●
IJ
(–24
9, –
31)
● A
CC
P (
358,
874
)E
lder
ly O
bes
e:●
PS
U (
–51,
+13
3)●
MS
J (–
440,
–21
5)●
HB
(–3
57, –
126)
● I
J (–
174,
+31
)●
AC
CP
(45
7, 7
49)
PS
U e
quat
ion
unbi
ased
and
pr
ecis
e ac
ross
all
age
and
w
eigh
t gro
ups
(con
tinu
ed)
Tab
le 4
. (c
onti
nu
ed)
727
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Alv
es e
t al,
2009
93V
alid
atio
n st
udy
Dis
sim
ilar
pro
gnos
isO
verw
eigh
t or
obes
e IC
U
pati
ents
Mea
n B
MI
36.4
1 ±
9.03
kg/
m2
Fas
ting
, n =
42
Sta
ble
feed
ing,
n =
29
Com
pare
RE
E m
easu
red
by D
elta
trac
cal
orim
eter
w
ith
esti
mat
es b
y H
B, I
J eq
uati
ons,
and
21
kcal
/kg
of
actu
al, a
vera
ge, a
nd a
djus
ted
body
wei
ght
Acc
ura
cy (
Con
cord
ance
Cor
rela
tion
C
oeff
icie
nt)
:F
aste
d m
easu
res:
● H
B a
ctua
l wei
ght (
0.76
7)●
IJ
actu
al w
eigh
t (0.
452)
● 2
1 kc
al/k
g ac
tual
wei
ght (
0.44
6)F
ed m
easu
res:
● H
B a
ctua
l wei
ght (
0.82
9)●
IJ
actu
al w
eigh
t (0.
641)
● 2
1 kc
al/k
g ac
tual
wei
ght (
0.49
0)B
ias:
Fas
ted
mea
sure
s:●
HB
act
ual w
eigh
t –81
.3 (
–726
.1, +
563.
4)●
IJ
actu
al w
eigh
t –64
4.2
(–13
69.8
, +81
.4)
● 2
1 kc
al/k
g ac
tual
wei
ght –
413.
3 (–
1527
.7,
+70
1)F
ed m
easu
res:
● H
B a
ctua
l wei
ght –
63.7
(–6
58.3
, +53
0.8)
● I
J ac
tual
wei
ght 4
61.9
(–1
72.7
, +10
96.5
)●
21
kcal
/kg
actu
al w
eigh
t +31
5.9
(–92
4.5,
+
1555
.7)
Use
of
adju
sted
bod
y w
eigh
t pro
duce
d le
ss
accu
rate
est
imat
es
RE
E s
houl
d be
mea
sure
dB
ias
wit
h be
st e
quat
ion
coul
d re
sult
in c
hang
e in
bod
y w
eigh
t if
appl
ied
to e
nerg
y de
live
ry
And
ereg
g et
al,
2009
55V
alid
atio
n st
udy
Dis
sim
ilar
pro
gnos
isD
iffe
rent
mea
suri
ng
devi
ces
Sm
all s
ampl
e
Hos
pita
lize
d ad
ult p
atie
nts
wit
h B
MI
38.2
± 8
kg/
m2
Ven
tila
ted,
n =
27
Spo
ntan
eous
ly b
reat
hing
, n =
9T
otal
N =
36
Iden
tify
whi
ch o
f 4
pred
icti
ve
equa
tion
s ga
ve e
stim
ates
w
ithi
n 10
% o
f m
easu
red
ener
gy e
xpen
ditu
re b
y D
elta
trac
(ve
ntil
ated
) or
M
edge
m (
spon
tane
ousl
y br
eath
ing)
.
Acc
ura
cy:
● H
B a
ctua
l wei
ght (
38.9
%)
● M
SJ
(19.
4%)
● I
J ve
ntil
ator
(38
.9%
)●
21
kcal
/kg
actu
al w
eigh
t (41
.5%
)B
ias
(mea
n ±
SD
):●
HB
110
.1 ±
478
.3●
MS
J 21
5.8
± 47
0.7
● I
J 15
2.3
± 39
9.1
● 2
1 kc
al/k
g ac
tual
wei
ght –
271
± 64
1.7
Mea
n R
EE
:●
Ven
tila
ted
20.4
± 5
.1 k
cal/
kg/d
● S
pont
aneo
usly
bre
athi
ng, 1
5.5
± .9
kca
l/kg
/d
Indi
rect
cal
orim
etry
sho
uld
be e
mpl
oyed
to m
easu
re
ener
gy e
xpen
ditu
re in
obe
se
hosp
ital
ized
pat
ient
s
Bou
llat
a et
al,
2007
54R
etro
spec
tive
rec
ord
vali
dati
on s
tudy
Dis
sim
ilar
pro
gnos
isU
ncle
ar h
ow m
any
obes
e pa
tien
ts a
re v
enti
lato
r vs
can
opy
mea
sure
s
All
pat
ient
s w
ith
an R
EE
in
1991
, n =
395
Ven
tila
tor
mea
sure
s, n
= 1
41C
anop
y m
easu
res,
n =
254
Obe
se, n
= 5
1
Eva
luat
e th
e ac
cura
cy o
f 7
pred
icti
ve e
quat
ions
ag
ains
t mea
sure
d R
EE
in
hos
pita
lize
d pa
tien
ts,
incl
udin
g th
e cr
itic
ally
ill
and
obes
e
Acc
ura
cy:
● H
B a
ctua
l wei
ght (
62%
)●
IJ
(32%
)B
ias:
● H
B +
47 (
–440
, +53
4)
Dat
a co
llec
tion
pre
date
s cu
rren
t le
vel o
f ob
esit
y
Tab
le 4
. (c
onti
nu
ed)
(con
tinu
ed)
728
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Dob
ratz
et a
l, 20
0757
Val
idat
ion
stud
yS
imil
ar p
rogn
osis
Sm
all s
ampl
e
Fem
ale
pre–
bari
atri
c su
rger
y pa
tien
ts, n
= 1
4B
MI
49.8
± 6
.2, (
rang
e 41
.3-
65.3
) kg
/m2
Iden
tify
whi
ch o
f 12
pre
dict
ion
equa
tion
s is
mos
t acc
urat
e re
lati
ve to
mea
sure
d R
EE
us
ing
Del
tatr
ac c
alor
imet
er
Acc
ura
cy:
● M
SJ
(86%
)●
HB
act
ual w
eigh
t (69
%)
Bia
s (m
ean
dif
fere
nce
):●
MS
J –4
8 ±
191
kcal
● H
B a
ctua
l wei
ght –
89 ±
187
kca
l/da
yU
se o
f ad
just
ed b
ody
wei
ght w
ith
HB
equ
atio
n m
ade
the
unde
rest
imat
e w
orse
Err
or f
or a
ll p
redi
ctiv
e eq
uati
ons
(inc
ludi
ng
MS
J) ≥
250
kca
l
Sm
all s
ampl
eC
lini
call
y st
able
pri
or to
bar
iatr
ic
surg
ery
Pre
dict
ion
erro
r m
ight
res
ult
in c
hang
e in
bod
y w
eigh
t if
appl
ied
to e
nerg
y de
live
ry
Fra
nken
fiel
d et
al,
2003
56V
alid
atio
n st
udy
Hea
lthy
vol
unte
ers
and
bari
atri
c su
rger
y pa
tien
ts in
a
hosp
ital
set
ting
All
can
opy
mea
sure
s, B
MI
rang
e up
to 9
6.8
kg/m
2
Non
obes
e, n
= 8
3B
MI
30-3
9.9,
n =
20
BM
I ≥
40, n
= 2
7
Eva
luat
e eq
uati
ons
for
pred
icti
ng r
esti
ng m
etab
olic
ra
te a
gain
st m
easu
red
valu
es
in o
bese
and
non
obes
e pe
ople
Acc
ura
cy o
f M
SJ:
● B
MI
30-3
9.9
(70%
), 1
0% u
nder
esti
mat
es,
20%
ove
rest
imat
es●
BM
I ≥
40 (
70%
), 7
% u
nder
esti
mat
es, 2
3%
over
esti
mat
esA
ccu
racy
of
HB
:●
BM
I 30
-39.
9 (5
0%),
40%
und
eres
tim
ates
, 10
% o
vere
stim
ates
BM
I ≥
40 (
74%
), 2
2% u
nder
esti
mat
es, 4
%
over
esti
mat
es
Bia
s is
the
95%
CI
of d
iffe
renc
e be
twee
n es
tim
ated
and
mea
sure
d R
EE
; pre
cisi
on is
the
perc
enta
ge o
f m
easu
res
± 10
% R
EE
. AC
CP
, Am
eric
an C
olle
ge o
f C
hest
Phy
sici
ans;
CI,
con
fide
nce
inte
rval
; H
B, H
arri
s–B
ened
ict;
IC
U, i
nten
sive
car
e un
it; I
J, I
reto
n-Jo
nes;
MS
J, M
iffl
in–S
t Jeo
r; P
SU
, Pen
n S
tate
Uni
vers
ity;
RE
E, r
esti
ng e
nerg
y ex
pend
itur
e.
Tab
le 4
. (c
onti
nu
ed)
Choban et al 729
5 studies reviewed compared multiple predictive equations (Harris–Benedict, Schofield, Mifflin–St Jeor, and others) with REE but did not include all the same predictive equations in each. All included very small samples of obese patients, 1 reported on data collected in 1991,54 and 1 used measures from 2 different calorimeter devices.55 Accuracy ( ± 10% of REE) varied among the equations studied with Mifflin–St Jeor (MSJ) demonstrating the highest accuracy at 70%56-86%57 compared with 50% for Harris–Benedict with adjusted weight55 and 50%,56 62%54-69%57 for Harris–Benedict using actual weight. In addition, significant bias55 and prediction errors54,57 were measured that could result in undesired weight changes when applied to specific patients. The error for MSJ, however, was lower than that demonstrated with Harris–Benedict using actual weight.56,57
The MSJ58 equations are as follows:
•• Men (kcal/day) = 5 + 10 × Weight (kg) + 6.25 × Ht(cm) – 5 × Age(y)
•• Women (kcal/day) = –161 + 10 × Weight (kg) + 6.25 × Ht(cm) – 5 × Age(y)
Whether provision of energy requirements based on REE provides superior clinical outcomes in hospitalized patients to those with energy needs estimated by a predictive equation has not yet been evaluated in patients with obese or optimal BMI.
Question 3: Are Clinical Outcomes Improved With Hypocaloric, High Protein Diets in Hospitalized Patients With Obesity? (Tables 5-6)
Recommendation3a. Clinical outcomes are at least equivalent in patients
supported with high protein hypocaloric feeding to those sup-ported with high protein eucaloric feeding. A trial of hypoca-loric high protein feeding is suggested in patients who do not have severe renal or hepatic dysfunction (weak). Hypocaloric feeding may be started with 50%-70% of estimated energy requirements or < 14 kcal/kg actual weight. High protein feed-ing 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.Evidence Grade: Low.
3b. Hypocaloric low protein feedings are associated with unfavorable outcomes. Clinical vigilance for adequate protein provision is suggested in patients who do not have severe renal or hepatic dysfunction (weak).Evidence Grade: Low.
Rationale. Insulin resistance, glucose intolerance, hyperlipid-emia, nonalcoholic fatty liver disease, and hypoventilation syndrome are more prevalent in patients with obesity than non-obese patients.59 As a result, the hospitalized patient with
obesity is susceptible to experiencing complications associated with overfeeding. Because of these concerns, hypocaloric, high protein regimens have been designed by clinicians in an effort to minimize potential overfeeding complications while simultaneously achieving net protein anabolism.
Hypocaloric feeding is defined as providing a caloric intake less than measuredor estimated energy expenditure whereas eucaloric feeding is intended to provide a caloric intake suffi-cient to meet caloric needs as assessed by measured energy expenditure. Hypercaloric feeding is the provision of a caloric intake greater than caloric requirements. Hypocaloric, high protein feeding is often mistaken for permissive underfeeding. Permissive underfeeding allows for both protein and caloric deficits whereas the intent of hypocaloric, high protein diets is to provide only a calorie deficit while ensuring adequate pro-tein intake.
Four comparative studies59-62 and 2 case series63,64 exam-ined the use of hypocaloric, high protein nutrition therapy for hospitalized patients with obesity. The hypocaloric, high pro-tein diets contained average intakes ranging from 90 g to 140 g of protein and 900 kcals to 1300 kcals daily (Table 4). Significantly improved clinical outcomes, as evidenced by decreased LOS in the ICU, decreased duration of antibiotic therapy, and a trend toward decreased days of mechanical ven-tilation, were suggested in a single small observational study examining hypocaloric, high protein diets vs eucaloric, high protein diets for critically ill trauma patients with obesity.61 Positive clinical outcomes were also noted for use of hypoca-loric, high protein feeding in 2 observational case series of sur-gical patients with obesity.63,64 In the only randomized controlled trial that examined clinical outcomes,59 no differ-ence in mortality or length of hospital stay was found for hos-pitalized patients with obesity who received hypocaloric high protein feeding when compared with eucaloric high protein diets. All 3 comparative studies59-61 indicated that nutrition out-comes, such as nitrogen balance and serum protein response, were similar between eucaloric and hypocaloric feeding in the presence of adequate protein intake. However, 1 large observa-tional study indicated a worsened 60-day mortality rate when a hypocaloric diet was combined with a low protein intake (aver-age daily caloric and protein intakes of 1000 kcals and 46 g, respectively) and given to hospitalized patients with Class II (BMI 35-39.9 kg/m2) obesity.65
The current literature, which includes a total of 163 patients supported with hypocaloric, high protein regimens, indicates that clinical outcomes for hospitalized patients with obesity are at least equivalent, if not improved, by the provision of hypo-caloric feeding when adequate protein intake is given to achieve net protein anabolism. A large randomized controlled trial is warranted to ascertain whether hypocaloric, high pro-tein nutrition therapy offers a significant therapeutic advantage over eucaloric or hypercaloric feeding with respect to clinical outcomes and avoidance of complications from overfeeding for hospitalized patients with obesity.
730
Tab
le 5
. E
vide
nce
Sum
mar
y Q
uest
ion
3: A
re C
lini
cal O
utco
mes
Im
prov
ed W
ith
Hyp
ocal
oric
, Hig
h P
rote
in D
iets
in H
ospi
tali
zed
Pat
ient
s?
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Dic
kers
on e
t al
, 201
362R
etro
spec
tive
coh
ort
obse
rvat
ion
Adm
issi
ons
to tr
aum
a ce
nter
, 20
09-2
011
wit
h B
MI ≥
30
kg/m
2
BM
I =
35
± 6
kg/m
2
Wei
ght =
105
± 2
6 kg
Age
18-
59 y
ears
, n =
41
Age
≥ 6
0 ye
ars,
n =
33
Exa
min
e w
heth
er o
lder
, cri
tica
lly
ill t
raum
a pa
tien
ts w
ho a
re o
bese
ac
hiev
e ni
trog
en e
quil
ibri
um a
nd
obta
in s
imil
ar c
lini
cal o
utco
mes
to
you
nger
obe
se p
atie
nts
duri
ng
hypo
calo
ric,
hig
h pr
otei
n th
erap
y
Dai
ly N
utr
ien
t D
eliv
ery:
● Y
oung
er: 1
8 kc
al/k
g id
eal w
eigh
t, pr
otei
n 1.
9 g/
kg id
eal w
eigh
t●
Old
er: 2
1 kc
al/k
g id
eal w
eigh
t, pr
otei
n 2.
1 g/
kg id
eal w
eigh
t (P
< .0
5)IC
U L
OS
:28
± 1
7 vs
30
± 13
day
s in
you
nger
vs
olde
rH
osp
ital
LO
S:
45 ±
30
vs 3
4 ±
14 d
ays
in y
oung
er v
s ol
der,
P
= .0
65S
epsi
s:83
% v
s 76
% in
you
nger
vs
olde
r, P
= .0
41P
neu
mon
ia:
39%
vs
48%
in y
oung
er v
s ol
der
An
tib
ioti
c d
ays
adju
sted
for
mor
tali
ty:
10 ±
3 v
s 8
± 4
days
in y
oung
er v
s ol
der,
P =
.0
41
Ham
ilto
n et
al,
2011
63R
etro
spec
tive
rec
ord
revi
ewN
o co
ntro
lS
mal
l sam
ple
Bar
iatr
ic s
urge
ry p
atie
nts
adm
itte
d fo
r in
itia
tion
of
hom
e P
N to
trea
t bow
el
obst
ruct
ion
or le
ak/f
istu
la,
2000
-200
8 w
ith
foll
ow-u
p da
ta f
rom
hom
eB
asel
ine
BM
I =
39.
8 (I
QR
36
.1, 4
8.1)
Bas
elin
e w
eigh
t = 1
13 k
g (I
QR
94.
5, 1
34)
N =
23
Eva
luat
e ef
fect
of
hypo
calo
ric
PN
on
wei
ght l
oss,
alb
umin
leve
l, P
N
com
plic
atio
ns
Dai
ly N
utr
ien
t D
eliv
ery:
● E
nerg
y 13
.6 k
cal/
kg a
ctua
l bod
y w
eigh
t●
Pro
tein
132
.6 ±
6.6
g, 1
.2 ±
0.3
g/k
g bo
dy
wei
ght
Wei
ght
Los
s:●
–7.
0 ±
5.1%
in 1
.5 m
onth
sC
omp
lica
tion
s:●
Rea
dmis
sion
52.
5%
(con
tinu
ed)
731
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Alb
erda
et a
l, 20
0965
Pro
spec
tive
coh
ort
obse
rvat
ion
Som
e di
ffer
ence
s in
ca
rdio
vasc
ular
dx
at
adm
issi
on, s
imil
ar
AP
AC
HE
II
scor
eO
R a
djus
ted
for
nutr
itio
n da
ys, B
MI,
age
, ad
mis
sion
cat
egor
y, d
x,
AP
AC
HE
II
scor
e72
8 ob
ese
subj
ects
, but
<
200
in e
ach
of B
MI
35-
39.9
and
> 4
0 gr
oups
Adu
lt p
atie
nts
adm
itte
d to
1 o
f 16
7 IC
Us
in 3
7 co
untr
ies
● B
MI
< 2
0 kg
/m2 , n
= 2
89●
BM
I 20
-24.
9, n
= 9
37●
BM
I 25
-29.
9, n
= 8
18●
BM
I 30
-34.
9, n
= 3
95●
BM
I 35
-39.
9, n
= 1
62●
BM
I ≥
40, n
= 1
71T
otal
N =
277
2
Exa
min
e th
e re
lati
onsh
ip b
etw
een
amou
nt o
f en
ergy
and
pro
tein
pr
ovid
ed to
cli
nica
l out
com
es, a
nd
the
impa
ct o
f pr
eill
ness
BM
I on
ou
tcom
es
Dai
ly E
ner
gy I
nta
ke:
● B
MI
< 2
0 kg
/m2 , 9
94 ±
469
kca
l; 1
9.7
± 9.
6 kc
al/k
g●
BM
I 20
-24.
9, 1
024
± 49
0; 1
5.7
± 7.
5 kc
al/k
g ac
tual
wei
ght
● B
MI
25-2
9.9,
107
4 ±
536;
13.
6 ±
6.7
kcal
/kg
● B
MI
30-3
4.9,
100
8 ±
534
kcal
; 11.
2 ±
4.9
kcal
/kg
● B
MI
35-3
9.9,
100
9 ±
532
kcal
; 9.8
± 5
.1 k
cal/
kg●
BM
I ≥
40, 1
048
± 53
1 kc
al; 8
.1 ±
4.4
kca
l/kg
Dai
ly P
rote
in I
nta
ke:
● B
MI
< 2
0 kg
/m2 , 4
4.7
± 23
.4 g
; 0.9
± 0
.5 g
/kg
● B
MI
20-2
4.9,
46.
7 ±
25.9
g; 0
.7 ±
0.4
g/k
g●
BM
I 25
-29.
9,47
.5 ±
28.
3 g;
0.6
± 0
.3 g
/kg
● B
MI
30-3
4.9,
47.9
± 2
8.3
g; 0
.5 ±
0.3
g/k
g●
BM
I 35
-39.
9,45
.8 ±
29.
2 g;
0.4
± 0
.3 g
/kg
● B
MI ≥
40, 5
0.3
± 33
.3 g
; 0.4
± 0
.3 g
/kg
60-d
ay M
orta
lity
Per
100
0 k
cal/
day
In
crea
se
in E
ner
gy I
nta
ke:
● B
MI
< 2
0 kg
/m2 , O
R 0
.52
(95%
CI,
0.2
9-0.
95, P
= .0
3)●
BM
I 20
-24.
9, O
R 0
.62
(95%
CI,
0.4
4-0.
88, P
=
.007
)●
BM
I 25
-29.
9, O
R 1
.05
(95%
CI,
0.7
5-1.
49)
● B
MI
30-3
4.9,
OR
1.0
4 (9
5% C
I, 0
.64-
1.68
)●
BM
I 35
-39.
9, O
R 0
.36
(95%
CI,
0.1
6-0.
80, P
=
.012
)●
BM
I ≥
40, O
R 0
.63
(95%
CI,
0.3
2-1.
24)
60-d
ay M
orta
lity
per
30
g In
crea
se in
Pro
tein
In
tak
e:●
BM
I <
20
kg/m
2 , OR
0.6
0 (9
5% C
I, 0
.41-
0.87
, P =
.007
)●
BM
I 20
-24.
9, O
R 0
.81
(95%
CI,
0.6
6-0.
99, P
=
.036
)●
BM
I 25
-29.
9, O
R 0
.97
(95%
CI,
0.7
9-1.
19)
● B
MI
30-3
4.9,
OR
1.0
4 (9
5% C
I, 0
.79-
1.37
)●
BM
I 35
-39.
9, O
R 0
.62
(95%
CI,
0.3
9-0.
98, P
=
.039
)●
BM
I ≥
40, O
R 0
.72
(95%
CI,
0.5
1-1.
03)
Ene
rgy
and
prot
ein
targ
ets
for
pati
ents
wit
h ob
esit
y go
dow
n as
BM
I in
crea
ses
(20.
2 kc
al/k
g an
d 1.
0 g/
kg;
17.9
kca
l/kg
and
0.9
g/k
g,
15.0
kca
l/kg
and
0.8
g/k
g;
and
for
BM
I 30
-34.
9, 3
5-39
.9, ≥
40
resp
ecti
vely
)In
crea
sed
ener
gy a
nd p
rote
in
inta
ke m
ay b
e im
port
ant
for
pati
ents
wit
h B
MI
35-
39.9
, not
sig
nifi
cant
ly s
o fo
r B
MI ≥
40
Tab
le 5
. (c
onti
nu
ed)
(con
tinu
ed)
732
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Cho
ban
et a
l, 20
0566
Ret
rosp
ecti
ve r
ecor
d re
view
Obe
se a
dult
pat
ient
s fr
om 2
si
tes
BM
I 30
-39.
9 kg
/m2 , n
= 4
8B
MI ≥
40 k
g/m
2 , n =
22
Eva
luat
e pr
otei
n re
quir
emen
ts, u
sing
ni
trog
en b
alan
ce, i
n ho
spit
aliz
ed
pati
ents
wit
h ob
esit
y
Pro
tein
Req
uir
emen
t:IC
U P
atie
nts
:●
BM
I 30
-39.
9 kg
/m2 , 1
.9 g
/kg
idea
l bod
y w
eigh
t/da
y●
BM
I ≥
40 k
g/m
2 , 2.5
g/k
g id
eal b
ody
wei
ght/
day
Non
-IC
U P
atie
nts
:●
BM
I 30
-39.
9 kg
/m2 , 1
.7 g
/kg
idea
l bod
y w
eigh
t/da
y●
BM
I ≥
40 k
g/m
2 , 1.8
g/k
g id
eal b
ody
wei
ght/
day
Dic
kers
on e
t al
, 200
261R
etro
spec
tive
rec
ord
revi
ewS
imil
ar p
rogn
osis
Sm
all s
ampl
e
Obe
se a
dult
pat
ient
s w
ith
> 7
da
ys e
nter
al tu
be f
eedi
ng in
su
rgic
al I
CU
Bas
elin
e B
MI
41.3
± 4
.7 k
g/m
2 and
wei
ght 1
18 ±
41
kg
in h
ypoc
alor
ic,
36 ±
12.
4 kg
/m2 a
nd w
eigh
t 10
2 ±
36 k
g in
euc
alor
ic
grou
pH
ypoc
alor
ic a
s en
ergy
inta
ke
< 2
0 kc
al/k
g ad
just
ed b
ody
wei
ght a
nd p
rote
in in
take
2
g/kg
idea
l bod
y w
eigh
t, n
= 2
8E
ucal
oric
as
ener
gy in
take
≥
20 k
cal/
kg a
djus
ted
body
w
eigh
t and
pro
tein
2 g
/kg
idea
l bod
y w
eigh
t, n
= 1
2T
otal
N =
40
Eva
luat
e nu
trit
ion
and
clin
ical
ef
fica
cy o
f eu
calo
ric
vs h
ypoc
alor
ic
ente
ral f
eedi
ngD
aily
fee
ding
pla
n:●
Bot
h gr
oups
wit
h pr
otei
n 2
g/kg
id
eal b
ody
wei
ght (
1.2
g/kg
act
ual
wei
ght)
● E
ucal
oric
goa
l 25-
30 to
tal k
cal/
kg
adju
sted
bod
y w
eigh
t; a
ctua
l int
ake
18.5
-25.
9 kc
al/k
g cu
rren
t bod
y w
eigh
t and
0.8
-1.2
g p
rote
in/k
g cu
rren
t bod
y w
eigh
tH
ypoc
alor
ic g
oal <
20
kcal
/kg
adju
sted
bod
y w
eigh
t; a
ctua
l int
ake
13.4
-19.
2 kc
al/k
g cu
rren
t bod
y w
eigh
t and
0.7
-0.9
g p
rote
in/k
g cu
rren
t bod
y w
eigh
t
Act
ual
inta
ke:
● H
ypoc
alor
ic v
s E
ucal
oric
: 128
5 ±
325
kcal
, 90
± 2
4 g
prot
ein
vs 1
841
± 48
2 kc
al, 1
11 ±
32
g p
rote
in d
aily
Len
gth
of
ICU
Sta
y:●
Hyp
ocal
oric
vs
Euc
alor
ic, 1
8.6
± 9.
9 vs
28.
5 ±
16.1
day
s, P
< .0
3V
enti
lato
r D
ays:
● H
ypoc
alor
ic v
s E
ucal
oric
, 15.
9 ±
10.8
vs
23.7
±
16.6
day
s, P
= .0
9)D
ura
tion
An
tib
ioti
c T
her
apy:
● H
ypoc
alor
ic v
s E
ucal
oric
, 16.
6 ±
11.7
vs
27.4
±
17.3
day
s, P
= .0
3)N
utr
itio
n M
easu
res:
● N
o di
ffer
ence
in n
itro
gen
bala
nce,
cha
nge
in
prea
lbum
in o
r al
bum
in
Cho
ban
et a
l, 19
9759
RC
TB
alan
ced
prog
nosi
sB
lind
ed d
eliv
ery
of P
NIn
dire
ct o
utco
mes
Obe
se a
dult
pat
ient
s re
ferr
ed
for
PN
,B
MI
35 (
rang
e 26
-46.
5) k
g/m
2
Hyp
ocal
oric
hig
h pr
otei
n P
N,
n =
16
Euc
alor
ic h
igh
prot
ein
PN
, n
= 1
4T
otal
N =
30
Eva
luat
e ef
fica
cy o
f hy
poca
lori
c vs
eu
calo
ric
PN
wit
h pr
otei
n 2
gm/k
g id
eal b
ody
wei
ght
Dai
ly f
eedi
ng p
lan:
● E
ucal
oric
goa
l wit
h kc
al/n
itro
gen
150:
1, a
ctua
l int
ake
1936
± 1
98
kcal
and
108
± 1
4 g
prot
ein
(1.2
g/
kg a
ctua
l wei
ght,
2 g/
kg id
eal
wei
ght)
Hyp
ocal
oric
goa
l wit
h kc
al/n
itro
gen
75:1
, act
ual i
ntak
e 12
93 ±
299
kca
l an
d 12
0 ±
27 g
pro
tein
Dai
ly N
utr
ien
t D
eliv
ery:
● H
ypoc
alor
ic 1
293
± 29
8 no
npro
tein
kca
l, 12
0 ±
27 g
pro
tein
● E
ucal
oric
193
6 ±
198
nonp
rote
in k
cal,
108
± 14
g p
rote
inC
han
ge in
bod
y w
eigh
t●
Hyp
ocal
oric
vs
Euc
alor
ic: 0
± 6
.8 k
g vs
2.7
±
7kg
Ch
ange
in A
lbu
min
:●
Hyp
ocal
oric
vs
Euc
alor
ic: –
1 ±
2 g/
L v
s –2
±
2 g/
LN
itro
gen
Bal
ance
:●
Hyp
ocal
oric
vs
Euc
alor
ic, 4
.0 ±
4.2
vs
3.6
± 41
. g n
itro
gen
(con
tinu
ed)
Tab
le 5
. (c
onti
nu
ed)
733
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Bur
ge e
t al,
1994
60R
CT
Unb
lind
ed P
N d
eliv
ery
Indi
rect
out
com
esS
mal
l sam
ple
Obe
se p
atie
nts
refe
rred
for
PN
BM
I =
33
± 5.
5 kg
/m2
Wei
ght 7
7-11
4 kg
Hyp
ocal
oric
hig
h pr
otei
n P
N,
n =
9 v
sE
ucal
oric
hig
h pr
otei
n P
N,
n =
7T
otal
N =
16
Eva
luat
e im
pact
of
hypo
calo
ric
PN
on
nitr
ogen
bal
ance
Dai
ly f
eedi
ng p
lan:
● E
ucal
oric
goa
l wit
h kc
al a
t 100
%
RE
E, k
cal/
nitr
ogen
150
:1, a
ctua
l in
take
, act
ual i
ntak
e 24
92 ±
298
kc
al (
25 k
cal/
kg a
ctua
l wei
ght)
and
13
0 ±
15 g
pro
tein
(1.
2 g/
kg o
r 2
g/kg
idea
l wei
ght)
Hyp
ocal
oric
goa
l wit
h 50
% R
EE
and
kc
al/n
itro
gen
75:1
, act
ual i
ntak
e 12
85 ±
374
kca
l (14
kca
l/kg
act
ual
wei
ght)
and
111
± 3
2 g
prot
ein
(1.3
g/
kg a
ctua
l wei
ght,
2 g/
kg id
eal
wei
ght)
Dai
ly N
utr
ien
t D
eliv
ery:
● H
ypoc
alor
ic 5
85 ±
170
non
prot
ein
kcal
, 110
.9
± 32
g p
rote
in●
Euc
alor
ic 1
972
± 23
5 no
npro
tein
kca
l, 13
0 ±
15.5
g p
rote
inC
han
ge in
bod
y w
eigh
t●
Hyp
ocal
oric
vs
Euc
alor
ic: –
4.1
± 6.
kg
vs
–7.4
± 8
.4kg
(~4
.5%
vs7
.3%
)N
itro
gen
Bal
ance
:●
Hyp
ocal
oric
vs
Euc
alor
ic, 1
.3 ±
3.6
2 vs
2.83
±
6.9
g
Dic
kers
on e
t al
, 198
664P
rosp
ecti
ve c
ohor
tU
ncon
trol
led
Bal
ance
d pr
ogno
sis
Sm
all s
ampl
e
Obe
se, s
tres
sed
surg
ical
pa
tien
ts r
equi
ring
PN
Bas
elin
e w
eigh
t 127
± 6
0 kg
(r
ange
90-
302
kg)
N =
13
Eva
luat
e ef
fica
cy o
f hy
poca
lori
c,
high
-pro
tein
fee
ding
Dai
ly N
utr
ien
t D
eliv
ery:
● N
onpr
otei
n kc
al 8
81 ±
393
(51
%
RE
E)
● P
rote
in 1
29 g
or
2.1
± 0.
6 g/
kg id
eal
body
wei
ght o
r 1.
2 ±
0.5
g/kg
act
ual
wei
ght,
2.1
g/kg
idea
l wei
ght
Nit
roge
n B
alan
ce:
● +
2.4
g/da
yW
eigh
t L
oss:
● 2
.3 ±
2.7
kg/
wee
kW
oun
d H
eali
ng:
● A
ll f
istu
las
or d
ehis
cenc
e he
aled
by
35.8
±
18.1
day
sA
dve
rse
Eve
nts
in S
ingl
e P
atie
nts
:●
Ket
onur
ia●
Mil
d sk
in r
ash
that
res
pond
ed to
zin
c an
d li
pid
inta
ke●
Acu
te r
enal
fai
lure
due
to a
ntib
ioti
c th
erap
y●
Rea
dmis
sion
for
rec
urre
nt a
nast
omot
ic le
ak
AP
AC
HE
, Acu
te P
hysi
olog
y an
d C
hron
ic H
ealt
h E
valu
atio
n; B
MI,
bod
y m
ass
inde
x; I
CU
, int
ensi
ve c
are
unit
; IQ
R, i
nter
quar
tile
ran
ge; L
OS
, len
gth
of s
tay;
OR
, odd
s ra
tio;
PN
, par
ente
ral n
utri
tion
; R
CT
, ran
dom
ized
con
trol
led
tria
l.
Tab
le 5
. (c
onti
nu
ed)
734 Journal of Parenteral and Enteral Nutrition 37(6)
Table 6. GRADE Table Question 3: Are Clinical Outcomes Improved With Hypocaloric, High Protein Diets in Hospitalized Patients?
Comparison Outcome Quantity, Type Evidence Finding Final GRADEOverall Evidence
GRADE
Hypocaloric/high protein vs eucaloric/high protein
LOS 1 OBS 1 decreased61 Low Low
Nitrogen Balance 1 RCT, 3 OBS 4 no difference59-62 LowWeight Loss 1 RCT, 1 OBS 2 no difference59,60 Low
LOS, length of stay; OBS, observational study; RCT, randomized controlled trial.
Data to support this recommendation are in Table 3, where protein intake of 1.2 g/kg actual body weight (2 g/kg ideal body weight) daily was given to patients in 5 observational studies59-62,64 with hypocaloric or eucaloric energy intake. An additional study compared protein requirements based on nitrogen balance studies separately for ICU and non-ICU patients. The ICU patients required 2-2.5 g/kg/day and the non-ICU patients 1.8-1.9 g/kg/d to approach nitrogen equilib-rium with the higher requirements for those with BMI > 40 kg/m2.66 These studies included patients up to 302 kg and BMI 50.6 kg/m2, however most subjects were considerably below these levels. Data have not been found to establish reasonable nitrogen intake goals for patients beyond these limits. Nitrogen balance was similar at this level of protein intake whether energy intake was hypocaloric or eucaloric. These initial rec-ommendations should be adjusted using nitrogen balance stud-ies, with a goal of nitrogen equilibrium if possible (–4 to +4 g nitrogen/kg/d).61 While older studies may have suggested increase in albumin or prealbumin concentration as a goal for protein intake, a more recent appreciation of the strong impact of inflammation on these measures makes them unreliable as a marker of nutrition state in most ill, hospitalized patients.
Question 4: In Obese Patients Who Have Had Malabsorptive or Restrictive Surgical Procedures for Weight Loss, What Micronutrients Should Be Evaluated? (Tables 7-8)
RecommendationPatients who have undergone sleeve gastrectomy, gastric
bypass, or biliopancreatic diversion ± duodenal switch have increased risk of nutrient deficiency. In acutely ill hospitalized patients with history of these procedures, evaluation for evi-dence of depletion of iron, copper, zinc, selenium, thiamine, folate, and vitamins B
12, and D is suggested as well as repletion
of deficiency states. (weak).Evidence Grade: Low.
Rationale. Bariatric surgical procedures that change the capacity of the stomach facilitate weight reduction by restric-tion, that is, increasing satiety and reducing caloric intake.
Procedures that shorten small bowel absorptive capacity result in malabsorption of protein, energy and micronutrients to vary-ing degrees depending on construction of the anatomy. Bilio-pancreatic diversion ± duodenal switch (BPD ± DS) and Roux-en-Y gastric bypass (RYGB) combine these mecha-nisms. Micronutrient deficiency may well be a comorbidity of severe obesity in that it appears to increase in prevalence as the degree of obesity increases in populations who have had no prior bariatric surgery. This has been documented for alpha & beta carotene, beta cryptoxanthin, lutein/zeaxanthin, lycopene, total carotenoids, iron, selenium, vitamins A, C, D, B
6, B
12, and
folic acid.67-69
Twenty-one observational studies and 2 RCTs have investi-gated a variety of micronutrients. These have compared serum levels in cohorts of patients treated with different procedures and have included RYGB, sleeve gastrectomy (SG), BPD ± DS, and adjustable gastric band procedures. The duration of follow-up was generally short, with 16 studies covering 1-3 years,69-82 3 studies 4-5 years83-85 and 1 study 7 years.86 The study of longest duration documented no deficiency states in patients with restrictive procedures but no malabsorptive component; how-ever, the others have documented an increased risk of deficiency of iron, copper, zinc, selenium, thiamine, folate, and Vitamins B
12 and D as compared with preoperative populations.The proclivity of restrictive or malabsorptive procedures
to exacerbate or create micronutrient deficiency states has been acknowledged by recommendations for supplementa-tion published by the American Society for Metabolic and Bariatric Surgery and the Obesity Society.87 For all bariatric surgery patients, a daily multiple vitamin/mineral supplement is recommended with 2 daily doses for patients with SG, RYGB, and BPD. For all patients, at least 3000 IU vitamin D daily is recommended to achieve serum 25-hydroxyvitamin D levels > 30 ng/mL; 2 mg copper daily; iron 45-60 mg from diet and supplements; and vitamin B
12 should be given as
needed to maintain normal serum levels. All patients except those with BPD should take 1200-1500 mg calcium citrate daily. Evaluation of folic acid, iron and 25-hydroxyvitamin D should be done annually. Copper, zinc, selenium, and thia-mine should be monitored when patients have specific find-ings to suggest deficiency. As with other chronic or home medications, these vitamin supplements should be continued or resumed in hospitalized patients.
735
Tab
le 7
. E
vide
nce
Sum
mar
y Q
uest
ion
4: I
n O
bese
Pat
ient
s W
ho H
ave
Had
a M
alab
sorp
tive
or
Res
tric
tive
Sur
gica
l Pro
cedu
re, W
hat M
icro
nutr
ient
s S
houl
d B
e E
valu
ated
?
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Bec
kman
et a
l, 20
1379
Pro
spec
tive
coh
ort
obse
rvat
ion
Sm
all s
ampl
e
Wom
en w
ith
RY
GB
, N
= 2
0D
escr
ibe
seru
m 2
5(O
H)D
ch
ange
s an
d de
term
ine
if
FM
loss
and
vit
amin
D
inta
ke a
re a
ssoc
iate
d w
ith
chan
ges
in s
erum
leve
ls a
t 12
mon
ths
afte
r R
YG
B
25(O
H)D
incr
ease
d by
10
± 2
ng/m
L
by 1
2 m
onth
s3
pati
ents
sti
ll h
ad 2
5(O
H)D
< 2
0 ng
/m
LW
eigh
t, F
M, B
MI,
and
%E
WL
ch
ange
s w
ere
asso
ciat
ed w
ith
25(O
H)D
cha
nge
Aas
heim
et a
l, 20
1294
Pro
spec
tive
non
rand
omiz
ed
tria
lS
mal
l sam
ple
RY
GB
, n =
29
Lif
esty
le m
anag
emen
t, n
= 2
4
Ass
ess
chan
ge in
vit
amin
st
atus
in p
atie
nts
taki
ng
vita
min
sup
plem
ents
1
year
aft
er R
YG
B v
s li
fest
yle
man
agem
ent
cont
rols
All
vit
amin
s si
mil
ar b
etw
een
RY
GB
an
d co
ntro
l pat
ient
s ex
cept
vit
amin
A
low
er in
RY
GB
Dam
ms-
Mac
hado
, 20
1269
Ret
rosp
ecti
ve r
ecor
d re
view
Sim
ilar
pop
ulat
ion
Sm
all s
ampl
e
SG
, N =
54
Des
crib
e nu
trie
nt
defi
cien
cies
bef
ore
and
1, 3
, 6, a
nd 1
2 m
onth
s af
ter
SG
At l
east
51%
had
a m
icro
nutr
ient
de
fici
ency
pre
oper
ativ
ely:
● V
itam
in D
(83
%)
● I
ron
(29%
)●
Vit
amin
B6
(11%
)●
Vit
amin
B12
(9%
)●
Fol
ate
(6%
)●
Pot
assi
um (
7%)
By
12 m
onth
s af
ter
SG
, pre
vale
nce
of d
efic
ienc
ies
of th
e fo
llow
ing
nutr
ient
s in
crea
sed:
● V
itam
in B
6 (17
%)
● V
itam
in B
12 (
17%
)●
Fol
ate
(14%
)
Red
ucti
on in
gas
tric
aci
dity
m
ay b
e im
plic
ated
po
stop
erat
ivel
y w
ith
vita
min
s B
6, B
12; f
olat
e de
fici
ency
may
be
due
to
food
cho
ices
of
pati
ents
Gle
tsu-
Mil
ler,
20
1295
Ret
rosp
ecti
ve r
ecor
d re
view
wit
hP
rosp
ecti
ve c
ohor
t ob
serv
atio
nS
mal
l sam
ple
RY
GB
, N =
136
Des
crib
e nu
mbe
r of
RY
GB
pa
tien
ts w
ith
copp
er
defi
cien
cy a
nd a
ssoc
iate
d he
mat
olog
ical
and
ne
urol
ogic
alC
ompl
aint
s ov
er 1
2 m
onth
s.
Pre
vale
nce
of c
oppe
r de
fici
ency
, 9.6
%In
cide
nce
of c
oppe
r de
fici
ency
, 18.
8%C
onco
mit
ant c
ompl
icat
ions
incl
ude
anem
ia, l
euko
peni
a, a
nd v
ario
us
neur
omus
cula
r ab
norm
alit
ies.
Keh
agia
s et
al,
2011
76R
CT
of
surg
ical
pro
cedu
reIT
T a
naly
sis
5% a
ttri
tion
Sm
all s
ampl
e
Ran
dom
ized
to R
YG
B, N
=
30
or S
G, N
= 3
0D
escr
ibe
peri
oper
ativ
e sa
fety
and
3-y
ear
resu
lts
afte
r R
YG
B o
r S
G
Pre
oper
ativ
e n
utr
ien
t d
efic
ien
cies
:R
YG
B v
s S
G, n
ot s
igni
fica
ntly
di
ffer
ent
3 ye
ars
pos
top
erat
ivel
y:V
itam
in B
12 d
efic
ienc
y in
7/2
9 (2
4%)
in R
YG
B v
s 1/
28 (
3.5%
) in
SG
(con
tinu
ed)
736
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Lei
vone
n et
al,
2011
75R
etro
spec
tive
rec
ord
revi
ewS
mal
l sam
ple
Pat
ient
s ov
er a
ge 6
0 ye
ars
trea
ted
wit
h S
G, N
=
12 v
s pa
tien
ts <
age
59
year
s, N
= 4
3
Eva
luat
e di
ffer
ence
s in
re
cove
ry, w
eigh
t los
s, a
nd
vita
min
sta
tus
12 m
onth
s af
ter
SG
in y
oung
er v
s ol
der
pati
ents
Vit
amin
def
icie
nci
es:
● N
ot s
igni
fica
ntly
dif
fere
nt
de L
uis
et a
l, 20
1185
Ret
rosp
ecti
ve r
ecor
d re
view
No
info
rmat
ion
on
supp
lem
ent a
dher
ence
BP
D p
atie
nts
at
base
line
and
4 y
ears
po
stop
erat
ivel
yN
= 6
5
Eva
luat
e in
flue
nce
of B
PD
on
cop
per
and
zinc
leve
lsP
reva
len
ce o
f co
pp
er d
efic
ien
cy:
● P
reop
erat
ive,
67.
8%●
6 m
onth
s, 7
6.9%
● 1
2 m
onth
s, 7
6.9%
● 2
4 m
onth
s, 8
7.7%
● 3
6 m
onth
s, 8
7.7%
● 4
8 m
onth
s, 9
0.7%
Pre
vale
nce
of
zin
c d
efic
ien
cy:
● P
reop
erat
ive,
73.
8%●
6 m
onth
s, 7
3.8%
● 1
2 m
onth
s, 8
6.1%
● 2
4 m
onth
s, 8
6.1%
● 3
6 m
onth
s, 9
0.7%
● 4
8 m
onth
s, 9
0.7%
Def
icie
ncy
prev
alen
ce
incr
ease
s ov
er ti
me
Ala
sfar
et a
l, 20
1168
Con
trol
led
coho
rt
obse
rvat
ion
No
info
rmat
ion
on tr
ace
elem
ent i
ntak
e or
su
pple
men
t use
Bar
iatr
ic s
urge
ry p
atie
nts,
N
= 6
6, B
MI
= 4
5.3
Non
obes
e co
ntro
ls, N
=
44, B
MI
= 2
5.9
Com
pare
ser
um tr
ace
elem
ent (
copp
er, z
inc,
se
leni
um, m
agne
sium
) co
ncen
trat
ions
in
preo
pera
tive
bar
iatr
ic
surg
ery
vs n
onob
ese
cont
rol s
ubje
cts
Sel
eniu
m c
once
ntra
tion
sig
nifi
cant
ly
low
er in
obe
se p
atie
nts,
P <
.001
Bal
sa e
t al,
2011
83C
ohor
t obs
erva
tion
No
info
rmat
ion
on tr
ace
elem
ent s
uppl
emen
t use
RY
GB
, N =
52
BP
D, N
= 8
9C
ompa
re p
reva
lenc
e of
cop
per
and
zinc
de
fici
ency
in R
YG
B v
s B
PD
pat
ient
s
Pre
vale
nce
of
cop
per
def
icie
ncy
, R
YG
B v
s B
PD
:●
Pre
oper
ativ
e, 0
% v
s 0%
● 6
mon
ths,
0%
vs
17%
● 1
2 m
onth
s, 2
% v
s 13
%●
24
mon
ths,
0%
vs
24%
● 4
8 m
onth
s, 2
% v
s 22
%●
60
mon
ths,
2%
vs
13%
Pre
vale
nce
of
zin
c d
efic
ien
cy, R
YG
B
vs B
PD
:●
Pre
oper
ativ
e,12
% v
s 12
%●
6 m
onth
s, 6
% v
s 69
%●
12
mon
ths,
2%
vs7
0%●
24
mon
ths,
6%
vs
74%
● 4
8 m
onth
s, 1
5% v
s 46
%●
60
mon
ths,
21%
vs
45%
Cop
per
and
zinc
def
icie
ncie
s m
ore
com
mon
wit
h B
PD
than
RY
GB
, mor
e pr
eval
ent o
ver
tim
e
Tab
le 7
. (c
onti
nu
ed)
(con
tinu
ed)
737
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Ros
a et
al,
2011
96P
rosp
ecti
ve b
ioav
aila
bili
ty
stud
ies
Sm
all s
ampl
e
RY
GB
, N =
9D
escr
ibe
iron
and
zin
c pl
asm
a re
spon
se to
a
tole
ranc
e te
st b
efor
e an
d 3
mon
ths
afte
r R
YG
B.
Low
er p
lasm
a zi
nc r
espo
nse
(P <
.01)
an
d de
laye
d re
spon
se to
iron
inta
ke
afte
r R
YG
BT
he to
tal p
lasm
a ir
on c
once
ntra
tion
ar
ea o
ver
4 ho
urs
was
not
dif
fere
nt
afte
r su
rger
y (P
> .0
5)24
-hou
r ur
inar
y ir
on a
nd z
inc
excr
etio
n di
d no
t cha
nge
Geh
rer
et a
l, 20
1077
Ret
rosp
ecti
ve r
ecor
d re
view
2004
-200
6R
YG
B, N
= 8
6, S
G, N
=
50
Ass
ess
freq
uenc
y of
pre
- an
d 3-
year
pos
tope
rati
ve
vita
min
def
icie
ncie
s an
d th
e su
cces
s ra
te o
f th
eir
trea
tmen
t
Pre
oper
ativ
e an
d p
osto
per
ativ
e d
efic
ien
cies
:●
Vit
amin
B12
in R
YG
B (
58%
) vs
SG
(1
8%),
P <
.000
1●
Vit
amin
D in
RY
GB
(52
%)
vs S
G
(32%
), P
< .0
1A
ll d
efic
ienc
ies
trea
tabl
e
Sch
oute
n et
al,
2010
86R
CT
of
lapa
rosc
opic
ban
d vs
ope
n V
BG
, coh
ort
obse
rvat
ion
Dia
gnos
tic
sim
ilar
ity
Sm
all s
ampl
e m
ay la
ck
stat
isti
cal p
ower
Ori
gina
l stu
dyN
= 1
002
and
7-ye
ars
post
surg
ical
da
ta o
btai
ned
from
91
(91%
) w
ith
a m
ean
foll
ow-u
p of
84
mon
ths
lapa
rosc
opic
AG
B N
= 4
8V
BG
N =
43
Des
crib
e th
e lo
ng-t
erm
re
sult
s of
res
tric
tive
ba
riat
ric
proc
edur
es
incl
udin
g w
eigh
t los
s,
long
-ter
m c
ompl
icat
ions
, co
mor
bidi
ties
, re
oper
atio
ns, a
nd v
itam
in
stat
us
No
sign
ific
ant d
iffe
renc
es in
leve
ls o
f ir
on, z
inc,
fol
ic a
cid
or th
iam
ine,
vi
tam
in B
6, or
B12
bet
wee
n la
paro
scop
ic A
GB
and
VG
B g
roup
sN
o vi
tam
in d
efic
ienc
ies
wer
e pr
esen
t 7
year
s af
ter
rest
rict
ive
bari
atri
c su
rgic
al p
roce
dure
s
Sig
nori
et a
l, 20
1080
Ret
rosp
ecti
ve r
ecor
d re
view
RY
GB
pat
ient
s, N
= 1
23R
ecom
men
ded
to ta
ke
1200
-200
0 IU
vit
amin
D
dai
ly
Com
pare
vit
amin
D s
tatu
s pr
eope
rati
vely
vs
12
mon
ths
post
-RY
GB
25-O
H D
(ng
/mL
) 22
.7 ±
9.9
vs
29.7
±
14.1
, pre
op v
s 12
mon
ths
post
-R
YG
B, P
< .0
01
Sal
le e
t al,
2010
78R
etro
spec
tive
rec
ord
revi
ewB
aria
tric
sur
gery
pat
ient
s in
Ang
ers,
Fra
nce
RY
GB
, N =
266
SG
, N =
33
BP
D-D
S, N
= 2
5
Des
crib
e zi
nc a
nd n
utri
tion
st
atus
bef
ore
and
6, 1
2 an
d 24
mon
ths
afte
r R
YG
B, S
G, D
S
Pre
oper
ativ
e:Z
inc
defi
cien
cy (
9%)
24 m
onth
s po
stop
erat
ivel
y:●
RY
GB
(35
%)
● S
G (
18%
) at
12
mon
ths
● B
PD
-DS
( 92
%)
Iron
def
icie
ncy:
● R
YG
B (
38%
)●
SG
(25
%)
at 1
2 m
onth
s●
BP
D-D
S(
58%
)
Tab
le 7
. (c
onti
nu
ed)
(con
tinu
ed)
738
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Gol
dner
et a
l, 20
0981
RC
T d
ose-
resp
onse
tria
lS
mal
l sam
ple
Pat
ient
s w
ith
RY
GB
an
d da
ily
vita
min
D
supp
lem
ents
800
IU, N
= 1
320
00 I
U, N
= 1
350
00 I
U, N
= 1
5
Dos
e-re
spon
se tr
ial t
o de
fine
dos
e of
vit
amin
D
supp
lem
ent n
eede
d af
ter
RY
GB
Pre
oper
ativ
e se
rum
25(
OH
) D
:●
19.
1 ±
9.9
vs 1
5.0
± 9.
3 vs
22.9
±
10.3
nm
ol/L
in 8
00 v
s 20
00 v
s 50
00
IU g
roup
s, P
= .0
112
mon
ths
pos
t-R
YG
B:
● 2
7.5
± 31
.0 (
n =
9),
800
IU
● 6
0.2
± 37
.4 (
n =
9),
200
0 IU
● 6
6.1
± 42
.2 (
n =
10)
, 500
0 IU
No
hype
rcal
cem
ia
Rec
omm
ende
d to
sta
rt a
ll
pati
ents
at 2
000
IU/d
ay
Cou
paye
et a
l, 20
0972
Pro
spec
tive
coh
ort
Dif
fere
nce
in B
MI
by
trea
tmen
t gro
upS
mal
l sam
ple,
may
lack
st
atis
tica
l pow
erN
o ad
just
men
t for
in
flam
mat
ion
or B
MI
grou
p di
ffer
ence
Sin
gle
cent
er70
con
secu
tive
pat
ient
s w
ho h
ad u
nder
gone
ba
riat
ric
surg
ery
AG
B: N
= 4
9, B
MI
43R
YG
B: N
= 2
1, B
MI
49
Com
pare
the
vita
min
and
nu
trit
ion
stat
us b
efor
e an
d 1
year
aft
er b
aria
tric
su
rger
y in
pat
ient
s re
ceiv
ing
syst
emat
ized
nu
trit
ion
care
Def
icie
ncie
s of
thia
min
e, v
itam
in C
, an
d ir
on in
38%
, 47%
and
43%
of
AB
G p
atie
nts
preo
pera
tive
ly, n
ot
sign
ific
antl
y w
orse
ned
at 1
yea
rIn
RY
GB
pat
ient
s de
fici
enci
es o
f th
iam
ine,
iron
, vit
amin
C w
ere
in
25%
, 57%
, and
47%
pre
oper
ativ
ely,
w
ith
impr
ovem
ent i
n th
iam
ine
and
vita
min
C d
efic
ienc
ies
at 1
yea
r (1
2%*
P <
.05,
37%
, 10%
* P
< .0
5 re
spec
tive
ly)
CR
P a
nd f
ibri
noge
n im
prov
ed in
bot
h gr
oups
by
1 ye
ar
Vit
amin
sup
plem
ents
im
prov
ed p
osto
pera
tive
ou
tcom
es in
RY
GB
pa
tien
ts
Car
lin
et a
l, 20
0982
RC
TS
mal
l sam
ple
Com
pare
sup
plem
enta
tion
in
fem
ale
RY
GB
pa
tien
ts w
ith
50,0
00 I
U
vita
min
D w
eekl
y, N
=
30 v
sN
o vi
tam
in D
su
pple
men
tatio
n, N
= 3
0B
oth
rece
ived
800
IU
vi
tam
in D
and
150
0 m
g ca
lciu
m d
aily
Eva
luat
e th
e ef
fect
iven
ess
of 5
0,00
0 IU
vit
amin
D
wee
kly
to r
eple
nish
vi
tam
in D
sto
res
1 ye
ar
afte
r R
YG
B
Bas
elin
e 25
-hyd
roxy
vita
min
D:
● 1
9.7
± 8.
5 vs
18.
5 ±
9.4
ng/m
L,
inte
rven
tion
vs
cont
rol
12 M
onth
25-
hyd
roxy
vita
min
D:
● 3
7.8
± 15
.6 v
s 15
.2 ±
7.5
ng/
mL
, in
terv
enti
on v
s co
ntro
l (P
< .0
01)
● L
ess
decl
ine
in b
one
min
eral
den
sity
in
trea
tmen
tM
ore
freq
uent
res
olut
ion
of
hype
rten
sion
in tr
eatm
ent
Tab
le 7
. (c
onti
nu
ed)
(con
tinu
ed)
739
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Toh
et a
l, 20
0997
Ret
rosp
ecti
ve r
ecor
d re
view
Pro
gnos
tic
sim
ilar
ity
Sm
all s
ampl
eN
o ad
just
men
t for
su
pple
men
t adh
eren
ce
rate
s, in
tera
ctio
n of
w
eigh
t los
s w
ith
vita
min
st
atus
Pre
oper
ativ
e: n
= 2
32P
osto
pera
tive
:n
= 1
48; R
YG
B =
103
; S
G =
46
Des
crib
e pr
eval
ence
of
nutr
ient
def
icie
ncie
s in
pa
tien
ts w
ho p
rese
nt
for
bari
atri
c su
rger
y,
com
pare
wit
h 12
-mon
th
post
oper
ativ
e le
vels
Pre
oper
ativ
ely
● L
ow 2
5-O
H v
itam
in D
in 5
7%●
Low
iron
in 1
5.7%
● H
igh
CR
P in
58.
5%P
osto
pera
tive
ly,
● L
ow 2
5-O
H v
itam
in D
red
uced
to
30%
in R
YG
B, 4
3% in
SG
pat
ient
s●
Low
iron
unc
hang
ed●
Hig
h C
RP
impr
oved
to 1
3% a
nd
17%
in R
YG
B a
nd S
G p
atie
nts
● V
itam
in B
12 in
crea
sed
from
1%
to
11%
in R
YG
B●
Low
RB
C f
olat
e in
crea
sed
in R
YG
B
from
1%
to 1
2%
Incr
ease
d B
12 a
nd f
olat
e de
fici
enci
es w
ith
RY
GB
su
gges
t lac
k of
adh
eren
ce
wit
h su
pple
men
ts
Gas
teyg
er e
t al,
2008
74R
etro
spec
tive
rec
ord
revi
ewS
mal
l sam
ple
Adh
eren
ce w
ith
vita
min
su
pple
men
ts n
ot
eval
uate
d
Sin
gle
cent
erA
dult
pat
ient
s at
2 y
ear
foll
ow-u
p af
ter
RY
GB
N =
137
(11
0 w
omen
; 27
men
)L
engt
h of
Rou
x li
mb:
10
0cm
for
BM
I ≤
48.
0 an
d 15
0 cm
for
BM
I <
48.
0A
ll p
atie
nts
rece
ived
a
mul
tivi
tam
in
supp
lem
ent 1
-6 m
onth
s af
ter
RY
GB
Sup
plem
enta
tion
wit
h sp
ecif
ic n
utri
ents
pr
escr
ibed
for
val
ues
that
fel
l bel
ow th
e re
fere
nce
rang
e
Ass
ess
type
, fre
quen
cy,
and
patt
ern
of th
e de
velo
pmen
t of
nutr
itio
n de
fici
enci
es o
ver
the
firs
t 24
mon
ths
afte
r R
YG
B,
to d
eter
min
e th
e am
ount
of
sup
plem
ents
pre
scri
bed
and
to e
valu
ate
the
cost
of
trea
tmen
t.
Pat
ien
ts r
equ
irin
g su
pp
lem
enta
tion
:●
3 m
onth
s, 3
4%●
6 m
onth
s, 5
9%●
24
mon
ths,
98%
Mos
t fr
equ
ent
sup
ple
men
ts:
● V
itam
in B
12, i
ron,
cal
cium
/vit
amin
D
in 6
0%●
Fol
ate
in 4
0%●
Vit
amin
B6, z
inc,
mag
nesi
um in
15
%M
ean
su
pp
lem
ents
per
pat
ien
t:●
24
mon
ths,
2.9
± 1
.4●
Cos
t/ye
ar U
S$4
17.9
6
Nut
riti
on d
efic
ienc
ies
are
com
mon
pos
t RY
GB
de
spit
e m
ulti
vita
min
su
pple
men
tati
on
Mad
an e
t al,
2006
71R
etro
spec
tive
rec
ord
revi
ewS
mal
l sam
ple
Inco
mpl
ete
data
All
pat
ient
s un
derg
oing
la
para
scop
ic R
YG
B b
y 1
surg
eon
duri
ng a
6
mon
th p
erio
d.N
= 1
00O
nly
abou
t 30
pati
ents
w
ith
all v
itam
in le
vels
at
12
mon
ths
Des
crib
e pr
eope
rati
ve
and
1-ye
ar p
ost-
RY
GB
vi
tam
in a
nd tr
ace
min
eral
le
vels
Def
icie
nci
es, p
reop
erat
ive
vs
pos
top
erat
ive:
● V
itam
in A
, 7%
vs
16%
● V
itam
in B
12.
5% v
s 0%
● V
itam
in D
, 40%
vs
19%
(P
< .0
5)●
Zin
c, 2
8% v
s 36
%●
Iro
n, 1
4% &
6%
● S
elen
ium
, 58%
& 3
% (
P <
.001
)●
Fol
ate,
2%
vs
8%
Did
not
rep
ort t
hiam
ine
leve
ls
Tab
le 7
. (c
onti
nu
ed)
(con
tinu
ed)
740
Stu
dyS
tudy
Des
ign,
Qua
lity
Pop
ulat
ion,
Set
ting
, nS
tudy
Obj
ecti
veR
esul
tsC
omm
ents
Cle
men
ts e
t al,
2006
70R
etro
spec
tive
rec
ord
revi
ewA
ll p
atie
nts
wit
h la
paro
scop
ic R
YG
B,
2002
-200
4 (N
= 4
93)
wit
h 1-
and
2-y
ear
foll
ow-u
p, N
= 1
41
Eva
luat
e pr
eval
ence
of
vita
min
def
icie
ncy
afte
r R
YG
B
Vit
amin
Def
icie
nci
es:
● A
(11
%)
● C
(34
.6%
)●
D (
7%)
● T
hiam
ine
(18.
3%)
● R
ibof
lavi
n (1
3.6%
)●
B6 (
17.6
%)
● B
12 (
3.6%
)N
o di
ffer
ence
yea
r 1
vs y
ear
2 po
stop
erat
ivel
y
Skr
oubi
s et
al,
2002
84R
etro
spec
tive
rec
ord
revi
ewN
o da
ta o
n ad
here
nce
rate
sN
o da
ta o
n ba
seli
ne
com
orbi
d co
ndit
ions
Unc
lear
dat
a on
num
ber
of s
ubje
cts
at e
ach
tim
e po
int
Uni
vers
ity
med
ical
cen
ter
in G
reec
eN
= 1
74R
YG
B, N
= 7
9 (B
MI
45.6
±
4.9)
BP
D, N
= 9
5 (B
MI
57.2
±
6.1)
Com
pare
nut
riti
on
com
plic
atio
ns
and
effe
ctiv
enes
s of
mic
ronu
trie
nt
supp
lem
enta
tion
aft
er
RY
GB
and
BP
DA
ll p
atie
nts
rece
ived
a
mul
tivi
tam
in a
nd m
iner
al
supp
lem
ent a
nd 2
g o
f ca
lciu
m
Iron
def
icie
ncy
:●
Low
iron
and
fer
riti
n le
vels
in
crea
sed
wit
h bo
th s
urgi
cal
proc
edur
es o
ver
tim
eV
itam
in B
12 d
efic
ien
cy:
● I
ncre
ased
wit
h bo
th s
urgi
cal
proc
edur
es f
rom
pre
op to
4 y
ears
po
stop
wit
h R
YG
B 3
3%, B
PD
22%
Neg
ligi
ble
inci
denc
e of
hy
poal
bum
inem
ia
AG
B, a
djus
tabl
e ga
stri
c ba
ndin
g; B
MI,
bod
y m
ass
inde
x; B
PD
, bil
iopa
ncre
atic
div
ersi
on; C
RP
, C-r
eact
ive
prot
ein;
DS
, duo
dena
l sw
itch
; EW
L, e
xces
s w
eigh
t los
s; F
M, f
at m
ass;
IT
T, i
tent
ion
to tr
eat
anal
ysis
; IU
, int
erna
tion
al u
nit;
RC
T, r
ando
miz
ed c
ontr
olle
d tr
ial;
RY
GB
, Rou
x-en
-Y g
astr
ic b
ypas
s; S
G, s
leev
e ga
stre
ctom
y; V
BG
, ver
tica
l-ba
nded
gas
trop
last
y; 2
5(O
H)D
= 2
5-hy
drox
yvit
amin
D.
Tab
le 7
. (c
onti
nu
ed)
Choban et al 741
Table 8. GRADE Table Question 4: In Obese Patients Who Have Had a Malabsorptive Surgical Procedure, What Micronutrients Should Be Evaluated?
ComparisonOutcome/Nutrient
DeficiencyQuantity, Type
Evidence Finding Final GRADEOverall Evidence
GRADE
Preoperative to postoperative RYGB or BPD
Copper 3 OBS Increased83,85,95 Low Low
Zinc 3 OBS Increased83,85 Low
Iron 3 OBS Increased84,97 Very low
Selenium 1 OBS Low
Thiamine 1 OBS Increased72 Low
Folic acid 1 OBS Increased97 Low
Vitamin B12
2 OBS Increased84,97 Low
Vitamin D 5 OBS, 2 RCT Increased with supplements decreased97
Low
BPD = biliopancreatic diversion; OBS = observational study; RCT, randomized controlled trial; RYGB = Roux-en-Y gastric bypass.
Compliance with supplement ingestion has been variable, with BPD ± DS 55%, RYGB 25%.88 Patient follow-up with bariatric surgical programs, and hence routine surveillance of nutrition parameters, tends to diminish with time duration after the surgical procedure. The severity and prevalence of defi-ciency appears to increase with the interval of time after the procedure as well as with the degree of malabsorption induced by the procedure. Data evaluating micronutrient status in patients in the decades following bariatric surgical intervention are not available.
A.S.P.E.N. Board of Directors Providing Final Approval
Deborah A. Andris, MSN, APNP; Phil Ayers, PharmD, BCNSP, FASHP; Albert Baroccas, MD, FACS, FASPEN; Praveen S. Goday, MBBS, CNSC; Carol Ireton-Jones, PhD, RD, LD, CNSD; Tom Jaksic, MD, PhD; Lawrence A. Robinson, BS, MS, PharmD; Gordon Sacks, PharmD, BCNSP, FCCP; Daniel Teitelbaum, MD; Charles W. Van Way III, MD, FASPEN.
A.S.P.E.N. Clinical Guidelines Editorial Board
Charlene Compher, PhD, RD, CNSC, LDN, FADA, FASPEN; Nancy Allen, MS, MLS, RD; Joseph I. Boullata, PharmD, RPh, BCNSP; Carol L. Braunschweig, PhD, RD; Donald E. George, MD; Edwin Simpser, MD; and Patricia A. Worthington, MSN, RN, CNSN.
Acknowledgments
This unfunded project was completed by authors and reviewers using their time as volunteers.
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