As the prevalence of obesity in the United States has steadily increased, the number of obese patients in Intensive Care Units (ICU) has also increased to more than 25 percent of patients(1). According to a panel of experts recently convened by Nestle HealthCare Nutrition (NHCN) to discuss the issues of obesity in the critical care setting, many hospitals and health care professionals are struggling to deal with the unique nutritional needs of this patient population.
As many health care professionals struggle with how to best meet the nutritional needs of their obese critically-ill patients, they often resort to using guidelines and treatment protocols designed for patients of average weight. The lack of data leads to inconsistent treatment, particularly in the area of nutritional support. Positive patient outcomes and controlled costs could be associated with recommendations and guidelines uniquely developed for the obese patient.
NHCN gathered clinical experts from around the country for an Obesity in Critical Care workshop with the objective of discussing current practices and the need for guiding principles to make nutritional management of this patient population more streamlined, uniform and effective. It is currently anticipated that a full summary of discussions, findings and recommendations from the participants will be documented in a supplement of the Journal of Parenteral and Enteral Nutrition (JPEN) in 2011.
"The prevalence of obesity in our hospitals is increasing and the severity of obesity continues to escalate," said Lee Kaplan, M.D., Director, Massachusetts General Hospital Weight Center, and featured speaker in the workshop. "With more than 60 associated complications and known co-morbidities, obesity has a significant impact on both patients and the health care providers trying to treat them."
Obesity is a serious health concern because of its related complications and co-morbidities, including cardiovascular disease, metabolic disorders such as diabetes, and respiratory disease. The increased rate of infections and complications resulting from obesity can be significant, costly and affect treatment across all settings. Despite these issues, experts indicate that they are uncertain as to the unique nutrition needs of their obese patients and feel they are not armed with the right information to make informed decisions or the correct resources to meet their needs.
Participants in the Obesity in Critical Care workshop included:
- Stephen McClave, M.D., University of Louisville
- Robert Kushner, M.D., Northwestern University
- Lee Kaplan, M.D., Ph.D., Massachusetts General Hospital
- Craig McLain, M.D., University of Louisville
- Dympna Gallagher, Ed.D., St. Luke's-Roosevelt Hospital
- Laszlo Kiraly, M.D., Oregon Health and Science University
- Roland Dickerson, Pharm.D., University of Tennessee Health Science Center
- Ken Fujioka, M.D., Scripps Clinic
- Matt Cave, M.D., University of Louisville
- Juan Ochoa, M.D., Nestle HealthCare Nutrition and University of Pittsburgh
- Robert Martindale, M.D., Ph.D., Oregon Health and Science University
- Mark DeLegge, M.D., Medical University of South Carolina
- John Dibaise, M.D., Mayo Clinic
- John Drover, M.D., Queens University Canada
- Tom Frazier, M.D., University of Louisville
- Ryan Hurt, M.D., Ph.D., Mayo Clinic
- Charles Van Way, M.D., University of Missouri
Experts at the workshop agree that there is limited clinically-validated data specific to the nutritional management of this patient population in the critical care setting. In addition, there is little direction in developing guiding principles for the best treatment of the critically-ill obese patient. There is only one set of published nutrition guidelines that addresses nutrition and obesity and that is the 2009 Critical Care Nutrition Guidelines.
Dr. Stephen McClave, M.D., Professor of Medicine, University of Louisville, and moderator of the workshop reiterated, "the lack of consistent, standardized nutrition interventions for the obese, critically-ill patient means that some patients may be overfed, others may be underfed or malnourished, and others may not have their nutritional needs assessed at all. All of these scenarios can present problems with health outcomes and recovery rates."
"Because there is a known benefit with nutritional intervention in the early ICU stage, it behooves us to identify the best nutritional approach and formula prescription, and create a formal guidance for use by the medical community who struggle with these questions," said Robert Martindale, M.D., Ph.D., Chief of General Surgery, Oregon Health and Science University.
Consensus from the workshop also highlights that, based on the published nutrition guidelines that are currently available, existing nutrition formulas do not adequately meet the nutritional needs of the critically-ill obese patient. For example, many of the existing formulas do not contain an adequate amount of protein for this patient population. Adding protein or other elements into existing formulas manually at bedside is time consuming and may increase the risk of contamination issues(2). The viscosity of additives mixed at the bedside may also present challenges with tube delivery. Experts agree that new formulas should be developed to streamline care for these patients to help assure that they are receiving the appropriate nutrients, as well as the right caloric mix.
Dr. Martindale further reiterated, "Despite the fact that there are more than 200 medical formulas or supplements, we have yet to find a single formula that addresses the unique nutrition needs of the obese, acutely-ill patient."
"As a leader in providing solutions that meet the nutritional challenges of all patients, Nestle HealthCare Nutrition is committed to collaborating with these experts to identify the best approach for the critically-ill obese patient, and focusing our efforts on their valuable insights and recommendations," said Juan Ochoa, M.D., Medical and Scientific Director, Nestle HealthCare Nutrition.
About Nestle HealthCare Nutrition, Inc.
Nestle HealthCare Nutrition offers nutritional solutions for people with specific dietary needs related to illnesses, disease states or the special challenges of different life stages. Nestle HealthCare Nutrition is part of Nestle Health Science S.A., which became operational on January 1, 2011 and is a wholly owned subsidiary of Nestle S.A.
(1) Hogue et al. Intensive Care Medicine 2009:35; 1152-1170.
(2) Anderton et al. Clinical Nutrition. 1993;12(supp 1):s16-s32.