Hypoenergetic nutrition support in hospitalized obese patients: a simplified method for clinical application

Abstract

Nutrition support in obese hospitalized patients is controversial, with some practitioners advocating restricted energy or hypoenergetic feedings when patients are being actively treated for another disease. To eliminate the need for indirect calorimetry, this randomized, double-blind, prospective study was undertaken to determine whether obese hospitalized patients given a hypoenergetic parenteral regimen administered to provide 2 g protein x kg ideal body wt (IBW)(-1) x d(-1), could achieve nitrogen balance comparable with that of control subjects given isonitrogenous normoenergetic formula. Thirty obese hospitalized patients with an average body mass index (BMI; in kg/m2) of 35 were randomly assigned to the hypoenergetic [energy (kJ):nitrogen (g) = 314:1; energy (kcal):nitrogen (g) = 75:1; n = 16] or control [energy (kJ):nitrogen (g) = 628:1; energy (kcal):nitrogen (g) = 150:1; n = 14] formulas. The initial formula volume administered provided 2 g protein x kg IBW(-1) x d(-1). Nitrogen balance was determined on day 0 and weekly. The total daily energy intake [per kg actual body weight (ABW)] was 57 +/- 12 kJ (hypoenergetic) compared with 94 +/- 21 kJ (control), P < 0.001, and the nonprotein energy intake was 36 +/- 10 kJ (hypoenergetic) compared with 73 +/- 17 kJ (control), P < 0.001. Protein intake was the same per ABW, 2.0 +/- 0.2 and 2.0 +/- 0.1 g kg IBW(-1) x d(-1), NS, for the hypoenergetic and control formulas, respectively. Mean net nitrogen balance was not significantly different between the groups, even after patients were subgrouped by illness, nor was the percentage of patients achieving positive nitrogen balance. Duration of treatment averaged 10.5 +/- 2.6 d. Weight change did not differ significantly between groups. These data indicate that patients receiving hypoenergetic feedings providing 2 g protein x kg IBW(-1) x d(-1) achieved nitrogen balance comparable with patients given conventional total parenteral nutrition regimens, even when critically ill.

A.S.P.E.N. Clinical Guidelines

“…Insulin resistance, glucose intolerance, hyperlipidemia, nonalcoholic fatty liver disease, and hypoventilation syndrome are more prevalent in patients with obesity than nonobese 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.…”

“…Four comparative studies [59][60][61][62] and 2 case series 63,64 examined the use of hypocaloric, high protein nutrition therapy for hospitalized patients with obesity. The hypocaloric, high protein diets contained average intakes ranging from 90 g to 140 g of protein and 900 kcals to 1300 kcals daily (Table 4).…”

“…61 Positive clinical outcomes were also noted for use of hypocaloric, high protein feeding in 2 observational case series of surgical patients with obesity. 63,64 In the only randomized controlled trial that examined clinical outcomes, 59 no difference in mortality or length of hospital stay was found for hospitalized patients with obesity who received hypocaloric high protein feeding when compared with eucaloric high protein diets. All 3 comparative studies [59][60][61] indicated that nutrition outcomes, such as nitrogen balance and serum protein response, were similar between eucaloric and hypocaloric feeding in the presence of adequate protein intake.…”

“…63,64 In the only randomized controlled trial that examined clinical outcomes, 59 no difference in mortality or length of hospital stay was found for hospitalized patients with obesity who received hypocaloric high protein feeding when compared with eucaloric high protein diets. All 3 comparative studies [59][60][61] indicated that nutrition outcomes, 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 observational study indicated a worsened 60-day mortality rate when a hypocaloric diet was combined with a low protein intake (average 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/m 2 ) obesity.…”

Evidence-based Nutritional Support in the Intensive Care Unit

“…Choban et al 55 demonstrated better glucose control with lesser need for exogenous insulin, but with no difference in mortality between the 2 groups. Overall, the average total caloric intakes in those studies ranged from 11 to 14 total kcal/kg ABW per day or 22 to 25 total kcal/kg IBW per day.…”