Mara Lee Beebe, MS, RD, LD, CNSC

Clinical Nutrition Week HighlightsJanuary 21-24, 2012 • Orlando, Florida

Walt Disney World Swan and Dolphin Resort

Advancing the Science and Practice of Clinical Nutrition and Metabolism for 35 Years

Omega 3 Fatty Acids: History, Metabolism, and FunctionImmune-modulating Enteral Nutrition

Latest Critical Care/ICU ResearchEpanic Trial – early vs late parenteral nutritionPep uP Trial – increase protein and energy in takeIntercept Trial - EPA and GLA

Malnutrition and SarcopeniaICD 9 and ICD 10 codes

Parenteral NutritionSafe PN practices and Competency ProgramsSustainTM

Product ShortagesAdvanced RD Practice

Focused Physical Assessment SkillSmall bowel feeding tube placementResearch and publishing

Advancing the Science and Practice of Clinical Nutrition and Metabolism for 35 Years

Malnutrition Awareness and Advocacy

Malnutrition is epidemic in hospitals Disease-related malnutrition ranges between 20%

and 50% of hospitalized patients worldwide Many hospital patients are not even screened for

nutritional status Others are diagnosed as malnourished but are not

provided adequate nutritional therapy.

Malnutrition Awareness and AdvocacyMalnutrition Decreases

Malnutrition Increases

Immunocompetence Recovery from illness/

injury Mental state Tolerance of treatment Quality of life Prognosis GI, pulmonary, and

renal function

Rate, duration, severity of infections

Overall complication rate

Hard-to-heal wounds, pressure ulcers

Immobility, risk of falling Need of help and careMorbidity Mortality

Malnutrition Leads to Increased Heath Cares Costs

Nutritional Strategies can Reduce Hospital ReadmissionsReadmissions cost the US Medicare

program about $17 billion each year.

Poor nutrition is a risk factor for readmission.

Canadian Malnutrition Task Force

Oral nutrition supplement research

ASPEN Taskforce/AND Workgroup

• Which parameters should be used to diagnose malnutrition

• How should malnutrition be documented

• Correlation of current IDNT definitions with existing diagnostic coding terminology

Figure 1. Etiology-based malnutrition definitions.

White J V et al. JPEN J Parenter Enteral Nutr 2012;36:275-283

Copyright © by The American Society for Parenteral and Enteral Nutrition

Etiology Based Malnutrition DefinitionsStarvation-related Malnutrition

Chronic starvation without inflammation – anything that limits access to food; for example anorexia nervosa

Chronic Disease-related MalnutritionInflammation is chronic and of mild to moderate

degree – organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity

Acute Disease or Injury-related MalnutritionInflammation is acute and of severe degree –

major infection, burns, trauma or closed head injury

Proposed Systematic Approach to Assessment

• History and clinical diagnosis• Clinical signs / physical exam• Anthropometric data• Laboratory indicators• Dietary assessment• Functional outcomes

Current ICD‐9 Terminology forAdult Malnutrition Diagnosis

Coded separately from primary disease/Condition262 – Other Severe Protein‐Calorie Malnutrition263 – Other and Unspecified Protein‐Calorie

Malnutrition260 – Kwashiorkor*261 – Nutritional Marasmus*

* For use in pediatric populations from poorly resourced countries

* 2011 Estimates of hunger in US pediatric populations

* 1 in 5 children (16M)

Omega 3 Fatty Acids and ARDS

Gone Fishin'The Truth About Omega-3s in Critical Care

NutritionAbbott Nutrition Sponsored Symposium

ARDSNET EDEN OMEGA TrialNIH Sponsored 2x2x2 Clinical Trial

Bronchodilator vs placeboTrophic vs Full FeedsFish Oil & Antioxidant Supplement vs Placebo

Fish Oil & Antioxidant Supplement vs Placebo

JAMA. 2011;306(14):1574-1581. doi:10.1001/jama.2011.1435

From: Enteral Omega-3 Fatty Acid, γ-Linolenic Acid, and Antioxidant Supplementation in Acute Lung Injury

Study Stopped Due to Futility

Placebo group had lower mortality rate- 16.3%

Compared to the Omega 3 group- 26.6%

Also had more Vent and ICU free days.

Normal mortality 25-30% in other ICU studiesPlacebo group was doing better than normOmega 3 group was doing average

Criticism of Omega Eden

Bolus vs ContinuousUse of different control formula Control group received more calories and

protein Omega 3 group had more diarrhea2 x 2 x 2 design of study

Consensus of Expert PanelOverwhelming data showing the benefit of

Omega 3 and antioxidant containing formulas

Consensus of Expert Panel

We should not bolus Omega 3s and Antioxidants

More large multicenter trials of enteral formulas containing EPA/GLA/antioxidants compared to standard feedings are needed

Continued use of products like Oxepa is SAFE

References White J V et al. JPEN J Parenter Enteral Nutr 2012;36:275-283 Breedveld-Peters JJ, Reijven PL, Wyers CE, et al. Integrated nutritional intervention in the

elderly after hip fracture. A process evaluation. Clin Nutr. 2012; 31:199-205. E Pub 2011 Oct 28.

Gariballa S, Forster S, Walters S, et al. A randomized, double-blind, placebo-controlled trial of nutritional supplementation during acute illness. Am J Med. 2006;119:693-699.

Jensen GL, Mirtallo J, Compher C, et al. Adult starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. JPEN J Parenter Enteral Nutr. 2010;34:156-159.

Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health. 2011;8:514-527

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).McClave SA - JPEN J Parenter Enteral Nutr - 01-MAY-2009; 33(3): 277-316

Martindale R.G., McClave S.A., Vanek V.W., American College of Critical Care Medicine, A.S.P.E.N. Board of Directors , et al:  Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: executive summary.  Crit Care Med 37. (5): 1757-1761.2009

Rice TW, Wheeler AP, Thompson BT, et al; NHLBI ARDS Clinical Trials Network  Enteral omega-3 fatty acid, gamma-linolenic acid, and antioxidant supplementation in acute lung injury.  JAMA. 2011;306(14):1574-81.