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Pardo E, Jabaudon M, Godet T, Pereira B, Morand D, Futier E, Arpajou G, Le Cam E, Bonnet MP, Constantin JM. Dynamic assessment of prealbumin for nutrition support effectiveness in critically ill patients. Clin Nutr 2024; 43:1343-1352. [PMID: 38677045 DOI: 10.1016/j.clnu.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND & AIMS Serum prealbumin is considered to be a sensitive predictor of clinical outcomes and a quality marker for nutrition support. However, its susceptibility to inflammation restricts its usage in critically ill patients according to current guidelines. We assessed the performance of the initial value of prealbumin and dynamic changes for predicting the ICU mortality and the effectiveness of nutrition support in critically ill patients. METHODS This monocentric study included patients admitted to the ICU between 2009 and 2016, having at least one initial prealbumin value available. Prospectively recorded data were extracted from the electronic ICU charts. We used both univariable and multivariable logistic regressions to estimate the performance of prealbumin for the prediction of ICU mortality. Additionally, the association between prealbumin dynamic changes and nutrition support was assessed via a multivariable linear mixed-effects model and multivariable linear regression. Performing subgroup analysis assisted in identifying patients for whom prealbumin dynamic assessment holds specific relevance. RESULTS We included 3136 patients with a total of 4942 prealbumin levels available. Both prealbumin measured at ICU admission (adjusted odds-ratio (aOR) 0.04, confidence interval (CI) 95% 0.01-0.23) and its change over the first week (aOR 0.02, CI 95 0.00-0.19) were negatively associated with ICU mortality. Throughout the entire ICU stay, prealbumin dynamic changes were associated with both cumulative energy (estimate: 33.2, standard error (SE) 0.001, p < 0.01) and protein intakes (1.39, SE 0.001, p < 0.01). During the first week of stay, prealbumin change was independently associated with mean energy (6.03e-04, SE 2.32e-04, p < 0.01) and protein intakes (1.97e-02, SE 5.91e-03, p < 0.01). Notably, the association between prealbumin and energy intake was strongest among older or malnourished patients, those suffering from increased inflammation and those with high disease severity. Finally, prealbumin changes were associated with a positive mean nitrogen balance at day 7 only in patients with SOFA <4 (p = 0.047). CONCLUSION Prealbumin measured at ICU admission and its change during the first-week serve as an accurate predictor of ICU mortality. Prealbumin dynamic assessment may be a reliable tool to estimate the effectiveness of nutrition support in the ICU, especially among high-risk patients.
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Affiliation(s)
- Emmanuel Pardo
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Département d'Anesthésie-Réanimation, Hôpital Saint-Antoine, Assistance Publique-hôpitaux de Paris, 75012, Paris, France.
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France; iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Thomas Godet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France; Université Clermont Auvergne, Department of Healthcare Simulation, Clermont-Ferrand, F-63000, France; Université Clermont Auvergne, Inserm, Neuro-Dol, Clermont-Ferrand, F-63000, France
| | - Bruno Pereira
- Biostatistics and Data Management Unit, Department of Clinical Research and Innovation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Dominique Morand
- Direction de la Recherche Clinique (DRCI), CHU de Clermont-Ferrand, Clermont-Ferrand, F-63003, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France; iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Gauthier Arpajou
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Elena Le Cam
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Département d'Anesthésie-Réanimation, Hôpital Saint-Antoine, Assistance Publique-hôpitaux de Paris, 75012, Paris, France
| | - Marie-Pierre Bonnet
- Sorbonne Université, Département Anesthésie-Réanimation, Hôpital Armand Trousseau, DMU DREAM, GRC 29, AP-HP, Paris, France; Université Paris Cité, INSERM, INRA, Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, Maternité Port Royal, 53 Avenue de l'Observatoire, F-75014, Paris, France
| | - Jean-Michel Constantin
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Département d'Anesthésie-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-hôpitaux de Paris, 75013, Paris, France
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Qin Y, Pillidge C, Harrison B, Adhikari B. Pathways in formulating foods for the elderly. Food Res Int 2024; 186:114324. [PMID: 38729692 DOI: 10.1016/j.foodres.2024.114324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 05/12/2024]
Abstract
The growth of the elderly population worldwide is posing significant challenges to human society. The progressive physical and physiological changes occur with aging, including decreased appetite, incomplete digestion, and reduced absorption of nutrients. A common feature of many elderly people's diets is a deficiency in proteins (especially easily digestible ones) and micronutrients (e.g., vitamins, zinc, iron, and calcium). One of the solutions to this problem is the incorporation of these components into suitably texture-modified foods. There is a dearth of products that meet the needs of the elderly with special medical/health conditions such as dysphagia, osteoporosis, diabetes, and cardiovascular disease, as well as those who are in hospital and palliative care. Future research and development of foods for the elderly must address specific dietary needs of different subgroups of elderly people with underlying health conditions. The existence of different physical and physiological stages of the elderly means that their specific dietary requirements must be considered. This review summarizes current knowledge on nutritional requirements including those with underlying health problems and outlines the research and innovation pathways for developing new foods considering nutrition, texture, flavor, and other sensory aspects.
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Affiliation(s)
- Yuxin Qin
- School of Science, RMIT University, Melbourne, VIC 3083, Australia.
| | | | | | - Benu Adhikari
- School of Science, RMIT University, Melbourne, VIC 3083, Australia; The Centre for Advanced Materials and Industrial Chemistry (CAMIC), Melbourne, VIC 3083, Australia.
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Wang Y, Li Y, Li Y, Li H, Zhang D. Enteral feeding strategies in patients with acute gastrointestinal injury: From limited to progressive to open feeding. Nutrition 2024; 117:112255. [PMID: 37897987 DOI: 10.1016/j.nut.2023.112255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/21/2023] [Accepted: 09/29/2023] [Indexed: 10/30/2023]
Abstract
Acute gastrointestinal injury (AGI) is very common in critically ill patients, and its severity is positively correlated with mortality. Critically ill patients with digestive and absorption dysfunction caused by AGI face higher nutritional risks, making nutritional support particularly important. Early enteral nutrition (EN) support is extremely important because it can promote the recovery of intestinal function, protect the intestinal mucosal barrier, reduce microbiota translocation, reduce postoperative complications, shorten hospital stay, and improve clinical prognosis. In recent years, many nutritional guidelines have been proposed for critically ill patients; however, there are few recommendations for the implementation of EN in patients with AGI, and their quality of evidence is low. The use of EN feeding strategies in critically ill patients with AGI remains controversial. The aim of this review was to elaborate on how EN feeding strategies should transition from limited to progressive to open feeding and explain the time window for this transition.
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Affiliation(s)
- Youquan Wang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Yanhua Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Yuting Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Hongxiang Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Dong Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
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Chapman S, Roberts J, Roberts AJ, Ogden H, Izard R, Smith L, Chichger H, Struszczak L, Rawcliffe AJ. Pre-sleep protein supplementation does not improve performance, body composition, and recovery in British Army recruits (part 1). Front Nutr 2023; 10:1262044. [PMID: 38144428 PMCID: PMC10748761 DOI: 10.3389/fnut.2023.1262044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/13/2023] [Indexed: 12/26/2023] Open
Abstract
Dietary protein is crucial for optimising physical training adaptations such as muscular strength and mass, which are key aims for athletic populations, including British Army recruits. New recruits fail to meet the recommended protein intake during basic training (BT), with negligible amounts consumed in the evening. This study assessed the influence of a daily bolus of protein prior to sleep on performance adaptations, body composition and recovery in British Army recruits. 99 men and 23 women [mean ± standard deviation (SD): age: 21.3 ± 3.5 years, height: 174.8 ± 8.4 cm, body mass 75.4 ± 12.2 kg] were randomised into a dietary control (CON), carbohydrate placebo (PLA), moderate (20 g) protein (MOD) or high (60 g) protein (HIGH) supplementation group. Supplements were isocaloric and were consumed on weekday evenings between 2000 and 2100 for 12 weeks during BT. Performance tests (mid-thigh pull, medicine ball throw, 2 km run time, maximal push-up, and maximal vertical jump) and body composition were assessed at the start and end of BT. Dietary intake, energy expenditure, salivary hormones, urinary nitrogen balance, perceived muscle soreness, rating of perceived exertion, mood, and fatigue were assessed at the start, middle and end of BT. Protein supplementation increased protein intake in HIGH (2.16 ± 0.50 g⸱kg-1⸱day-1) and MOD (1.71 ± 0.48 g⸱kg-1⸱day-1) compared to CON (1.17 ± 0.24 g⸱kg-1⸱day-1) and PLA (1.31 ± 0.29 g⸱kg-1⸱day-1; p < 0.001). Despite this, there was no impact of supplementation on mid-thigh pull performance (CON = 7 ± 19%, PLA = 7 ± 19%, MOD = 0 ± 16%, and HIGH = 4 ± 14%; p = 0.554) or any other performance measures (p > 0.05). Fat-free mass changes were also similar between groups (CON = 4 ± 3%, PLA = 4 ± 4%, MOD = 3 ± 3%, HIGH = 5 ± 4%, p = 0.959). There was no impact of protein supplementation on any other body composition or recovery measure. We conclude no benefits of pre-bed protein supplementation to improve performance, body composition and recovery during BT. It is possible the training stimulus was great enough, limiting the impact of protein supplementation. However, the high degree of inter-participant variability suggests an individualised use of protein supplementation should be explored, particularly in those who consume sub-optimal (<1.6 g⸱kg-1⸱day-1) habitual amounts of protein. Clinical trial registration: The study was registered with ClinicalTrials.gov, U.S. national institutes (identifier: NCT05998590).
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Affiliation(s)
- Shaun Chapman
- Army Recruit Health and Performance Research, HQ Army Recruiting and Initial Training Command, Medical Branch, UK Ministry of Defence, Upavon, United Kingdom
- Cambridge Centre for Sport and Exercise Sciences, School of Psychology and Sport Science, Anglia Ruskin University, Cambridge, United Kingdom
| | - Justin Roberts
- Cambridge Centre for Sport and Exercise Sciences, School of Psychology and Sport Science, Anglia Ruskin University, Cambridge, United Kingdom
| | - Andrew J. Roberts
- Army Recruit Health and Performance Research, HQ Army Recruiting and Initial Training Command, Medical Branch, UK Ministry of Defence, Upavon, United Kingdom
| | - Henry Ogden
- Army Recruit Health and Performance Research, HQ Army Recruiting and Initial Training Command, Medical Branch, UK Ministry of Defence, Upavon, United Kingdom
| | - Rachel Izard
- Defence Science and Technology, UK Ministry of Defence, Salisbury, United Kingdom
| | - Lee Smith
- Centre for Health, Performance and Wellbeing, Anglia Ruskin University, Cambridge, United Kingdom
| | - Havovi Chichger
- Biomedical Science Research Group, School of Life Science, Anglia Ruskin University, Cambridge, United Kingdom
| | - Lauren Struszczak
- Public Health and Sports Sciences, University of Exeter, Exeter, United Kingdom
| | - Alex J. Rawcliffe
- Army Recruit Health and Performance Research, HQ Army Recruiting and Initial Training Command, Medical Branch, UK Ministry of Defence, Upavon, United Kingdom
- Faculty of Science and Engineering, Anglia Ruskin University, Cambridge, United Kingdom
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Dupuis C, Bret A, Janer A, Guido O, Bouzgarrou R, Dopeux L, Hernandez G, Mascle O, Calvet L, Thouy F, Grapin K, Couhault P, Kinda F, Laurichesse G, Bonnet B, Adda M, Boirie Y, Souweine B. Association of nitrogen balance trajectories with clinical outcomes in critically ill COVID-19 patients: A retrospective cohort study. Clin Nutr 2022; 41:2895-2902. [PMID: 36109282 PMCID: PMC9444301 DOI: 10.1016/j.clnu.2022.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/26/2022] [Accepted: 08/24/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS The intensity and duration of the catabolic phase in COVID-19 patients can differ between survivors and non-survivors. The purpose of the study was to assess the determinants of, and association between, nitrogen balance trajectories and outcome in critically ill COVID-19 patients. METHODS This retrospective monocentric observational study involved patients admitted to the intensive care unit (ICU) of the University Hospital of Clermont Ferrand, France, from January 2020 to May 2021 for COVID-19 pneumonia. Patients were excluded if referred from another ICU, if their ICU length of stay was <72 h, or if they were treated with renal replacement therapy during the first seven days after ICU admission. Data were collected prospectively at admission and during ICU stay. Death was recorded at the end of ICU stay. Comparisons of the time course of nitrogen balance according to outcome were analyzed using two-way ANOVA. At days 3, 5, 7, 10 and 14, uni- and multivariate logistic regression analyses were performed to assess the impact of a non-negative nitrogen-balance on ICU death. To investigate the relationships between nitrogen balance, inflammatory markers and protein intake, linear and non-nonlinear models were run at days 3, 5 and 7, and the amount of protein intake necessary to reach a neutral nitrogen balance was calculated. Subgroup analyses were carried out according to BMI, age, and sex. RESULTS 99 patients were included. At day 3, a similar negative nitrogen balance was observed in survivors and non-survivors: -16.4 g/d [-26.5, -3.3] and -17.3 g/d [-22.2, -3.8] (p = 0.54). The trajectories of nitrogen balance over time thus differed between survivors and non-survivors (p = 0.01). In survivors, nitrogen balance increased over time, but decreased from day 2 to day 6 in non-survivors, and thereafter increased slowly up to day 14. At days 5 and 7, a non-negative nitrogen-balance was protective from death. Administering higher protein amounts was associated with higher nitrogen balance. CONCLUSION We report a prolonged catabolic state in COVID patients that seemed more pronounced in non-survivors than in survivors. Our study underlines the need for monitoring urinary nitrogen excretion to guide the amount of protein intake required by COVID-19 patients.
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Affiliation(s)
- Claire Dupuis
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France,Université Clermont Auvergne, Unité de Nutrition Humaine, INRAe, CRNH Auvergne, F-63000, Clermont-Ferrand, France,Corresponding author.Service de Médecine Intensive et Réanimation, CHU Clermont Ferrand, France
| | - Alexandre Bret
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Alexandra Janer
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Olivia Guido
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Radhia Bouzgarrou
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Loïc Dopeux
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Gilles Hernandez
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Olivier Mascle
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Laure Calvet
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - François Thouy
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Kévin Grapin
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Pierre Couhault
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Francis Kinda
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | | | - Benjamin Bonnet
- CHU Clermont-Ferrand, Service d'Immunologie, Clermont-Ferrand, France,Université Clermont Auvergne, Laboratoire d’Immunologie, ECREIN, UMR1019 UNH, UFR Médecine de Clermont-Ferrand, Clermont-Ferrand, France
| | - Mireille Adda
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Yves Boirie
- Université Clermont Auvergne, Unité de Nutrition Humaine, INRAe, CRNH Auvergne, F-63000, Clermont-Ferrand, France,CHU Clermont-Ferrand, Service de Nutrition Clinique, Clermont-Ferrand, France
| | - Bertrand Souweine
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
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The effects of synbiotic supplementation on enteral feeding tolerance, protein homeostasis, and muscle wasting of critically ill adult patients: a randomized controlled trial. Trials 2022; 23:846. [PMID: 36195945 PMCID: PMC9531380 DOI: 10.1186/s13063-022-06668-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/18/2022] [Indexed: 12/03/2022] Open
Abstract
Background Enteral feeding intolerance, energy-protein malnutrition, and muscle wasting are common conditions in the critical care setting. The primary aim of this study was to investigate the effect of synbiotic supplementation on enteral feed volume, energy and protein homeostasis, and muscle mass maintenance in critically ill adult patients. Methods A consecutive of 42 patients admitted to the Edalatian Medical ICU, requiring enteral nutrition (EN), were prospectively randomized to receive the synbiotic capsule (containing a combination of Lactobacillus, Bifidobacterium, Streptococcus, and fructooligosaccharides) or placebo (21 patients in each group) for a maximum of 14 days. Enteral intolerance and energy homeostasis were evaluated on a daily basis. Nitrogen balance and 24-h urine creatinine excretion were recorded on days 1 and 14. Mid-arm circumference was recorded every 3 days. Results Mean EN volume, energy, and protein intake per day were 962.5 ± 533.82 ml, 770 ± 427.05 kcal, and 38.5 ± 21.35 g (fourth day) vs. 590 ± 321.1 ml, 472 ± 256.81 kcal, and 23.6 ± 12.84 g (first day) in the synbiotic group (p < 0.05). Changes in the placebo group were not statistically significant. On day 1, nitrogen balance (NB) was − 19.84 ± 8.03 in the synbiotic vs. − 10.99 ± 9.12 in the placebo group (p = 0.003). On day 14, NB was − 14.18 ± 13.05 in the synbiotic and − 9.59 ± 7.71 in the placebo group (p = 0.41). Mid-arm circumference (MAC), 24-h urine creatinine, and creatinine-height index were almost steady in the synbiotic group, while they decreased in the placebo group. Conclusion Overall, it can be concluded that enteral nutrition supplemented with synbiotics has no statistically significant effect on energy and protein homeostasis and muscle mass maintenance of critically ill patients on day 14, but it can increase enteral feed volume and energy and protein intake during the first 4 days of ICU admission. Trial registration The trial protocol has been approved in Iranian Registry of Clinical Trials on March 17, 2019. The registration reference is IRCT20190227042857N1.
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Zhu YB, Yao Y, Xu Y, Huang HB. Nitrogen balance and outcomes in critically ill patients: A systematic review and meta-analysis. Front Nutr 2022; 9:961207. [PMID: 36071933 PMCID: PMC9441883 DOI: 10.3389/fnut.2022.961207] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveNitrogen balance (NB) is a commonly used nutrition indicator in clinical practice, while its relation to the interpretation of protein malnutrition and outcomes in critically ill patients remains unclear. This study aimed to evaluate the impact of NB on prognosis in such a patient population.MethodsWe searched for relevant studies in PubMed, EMBASE, and the Cochrane Database up to May 10, 2022. Meta-analyses were performed to evaluate the relationship between NB (initial, final, or absolute change of NB levels) and prognosis and important clinical outcomes in critically ill patients. Pooled odds ratios (ORs) and mean differences (MDs) together with their 95% confidence intervals (CIs) were calculated. We also conducted subgroup analyses to explore the sources of heterogeneity.ResultsEight studies with 1,409 patients were eligible. These studies were moderate to high quality. When pooled, the initial NB was comparable between the survival and non-survival groups (five studies, MD 1.20, 95% CI, −0.70 to 3.11, I2 = 77%; P = 0.22), while a significantly higher final NB in the survival group than that in the death group (two studies, MD 3.69, 95% CI, 1.92–5.46, I2 = 55%; P < 0.0001). Two studies provided the absolute change of NB over time and suggested survival patients had more increased NB (MD 4.16 g/day, 95% CI, 3.70–4.61, I2 = 0%; P < 0.00001). Similarly, for studies utilizing multivariate logistic regression, we found an improved NB (four studies, OR 0.85, 95% CI, 0.73–0.99, I2 = 61%; P = 0.04) but not an initial NB (two studies, OR 0.92, 95% CI 0.78–1.08, I2 = 55%; P = 0.31) was significantly associated the risk of all-cause mortality. These results were further confirmed in subgroup analyses. In addition, patients with improved NB had more protein and calorie intake and a similar length of stay in hospital than those without.ConclusionsOur results suggested that an improved NB but not the initial NB level was associated with all-cause mortality in critically ill patients. This highlights the requirement for dynamic monitoring of NB during nutrition treatment. Further randomized clinical trials examining the impact of NB-guided protein intake on clinical outcomes in critically ill patients are warranted.Systematic review registrationINPLASY202250134, https://doi.org/10.37766/inplasy2022.5.0134.
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Affiliation(s)
- Yi-Bing Zhu
- Department of Emergency, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan Yao
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yuan Xu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Hui-Bin Huang
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- *Correspondence: Hui-Bin Huang
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Tetamo R, Fittipaldi C, Buono S, Umbrello M. Nutrition support for critically ill patients during the COVID-19 pandemic: the Italian SIAARTI survey. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022. [PMCID: PMC9361260 DOI: 10.1186/s44158-022-00063-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background
Critically ill, COVID-19 patients are characterized by a hypermetabolic state and a reduced food intake and are at high risk of malnutrition and lean body mass loss. An appropriate metabolic-nutritional intervention aims to reduce complications and improve the clinical outcomes. We conducted a cross-sectional, multicenter, observational, nationwide online survey involving Italian Intensivists to assess the nutritional practices in critically ill patients with COVID-19. Results A group of experts in nutrition of the Italian Society of Anaesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) developed a 24-item questionnaire; the 9000 members of the Society were invited to participate through emails and social networks. Data was collected from June 1 to August 1, 2021. A total of 545 responses were collected: 56% in northern, 25% in central, and 20% in southern Italy. Artificial nutrition support is directly handled by intensivists in > 90 of the cases; the nutritional status is assessed as suggested by the guidelines in more than 70% of the cases, and a form of nutrition support is started within the first 48 h from ICU admission by > 90% of the respondents. Nutritional targets are reached in 4–7 days in > 75% of the cases, mainly by the enteral route. Indirect calorimetry, muscle ultrasound, and bioimpedance analysis are used by a limited part of the interviewees. Only about a half of the respondents reported the nutritional issues in the ICU discharge summary. Conclusions This survey among Italian Intensivists during the COVID-19 epidemic showed how the beginning, progression, and route of nutritional support adhere to international recommendations, while recommendations on the tools to set the target and monitor the efficacy of the metabolic support are less followed. Supplementary Information The online version contains supplementary material available at 10.1186/s44158-022-00063-6.
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Zhang Z, Xiahou Z, Wu W, Song Y. Nitrogen Metabolism Disorder Accelerates Occurrence and Development of Lung Adenocarcinoma: A Bioinformatic Analysis and In Vitro Experiments. Front Oncol 2022; 12:916777. [PMID: 35903696 PMCID: PMC9315097 DOI: 10.3389/fonc.2022.916777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 06/16/2022] [Indexed: 11/25/2022] Open
Abstract
Background Nitrogen metabolism (NM) plays a pivotal role in immune regulation and the occurrence and development of cancers. The aim of this study was to construct a prognostic model and nomogram using NM-related genes for the evaluation of patients with lung adenocarcinoma (LUAD). Methods The differentially expressed genes (DEGs) related to NM were acquired from The Cancer Genome Atlas (TCGA) database. Consistent clustering analysis was used to divide them into different modules, and differentially expressed genes and survival analysis were performed. The survival information of patients was combined with the expressing levels of NM-related genes that extracted from TCGA and Gene Expression Omnibus (GEO) databases. Subsequently, univariate Cox analysis and the least absolute shrinkage and selection operator (LASSO) regression were used to build a prognostic model. GO and KEGG analysis were elaborated in relation with the mechanisms of NM disorder (NMD). Meanwhile, immune cells and immune functions related to NMD were discussed. A nomogram was built according to the univariate and multivariate Cox analysis to identify independent risk factors. Finally, real-time fluorescent quantitative PCR (RT-PCR) and Western bolt (WB) were used to verify the expression level of hub genes. Results There were 138 differential NM-related genes that were divided into two gene modules. Sixteen NM-related genes were used to build a prognostic model and the receiver operating characteristic curve (ROC) showed that the efficiency was reliable. GO and KEGG analysis suggested that NMD accelerated development of LUAD through the Wnt signaling pathway. The level of activated dendritic cells (aDCs) and type II interferon response in the low-risk group was higher than that of the high-risk group. A nomogram was constructed based on ABCC2, HMGA2, and TN stages, which was identified as four independent risk factors. Finally, RT-PCR and WB showed that CDH17, IGF2BP1, IGFBP1, ABCC2, and HMGA2 were differently expressed between human lung fibroblast (HLF) cells and cancer cells. Conclusions High NM levels were revealed as a poor prognosis of LUAD. NMD regulates immune system through affecting aDCs and type II interferon response. The prognostic model with NM-related genes could be used to effectively evaluate the outcomes of patients.
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Affiliation(s)
- Zexin Zhang
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhikai Xiahou
- China Institute of Sport and Health Science, Beijing Sport University, Beijing, China
| | - Wenfeng Wu
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yafeng Song
- China Institute of Sport and Health Science, Beijing Sport University, Beijing, China
- *Correspondence: Yafeng Song,
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Batitucci G, Faria Junior EV, Nogueira JE, Brandão CFC, Abud GF, Ortiz GU, Marchini JS, Freitas EC. Impact of Intermittent Fasting Combined With High-Intensity Interval Training on Body Composition, Metabolic Biomarkers, and Physical Fitness in Women With Obesity. Front Nutr 2022; 9:884305. [PMID: 35694163 PMCID: PMC9178202 DOI: 10.3389/fnut.2022.884305] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/25/2022] [Indexed: 01/25/2023] Open
Abstract
BackgroundIntermittent fasting (IF) is a dietary approach that is widely popular due to its effects on weight and body fat loss, but it does not appear to ensure muscle mass preservation. Incorporating high-intensity interval training (HIIT) into an individual’s routine could be an attractive and viable therapeutic option for improving body composition, lifestyle and health promotion. Problematizing the emerging situation of fighting obesity, led us to clarify gaps about IF and hypothesize that IF and HIIT in conjunction may protect against muscle mass decline without impairing nitrogen balance (NB), in addition to improving the physical fitness of women with obesity.ObjectivesTo evaluate the effects of IF alone and combined with HIIT on body composition, NB and strength and physical fitness in women with obesity.MethodsThirty-six women (BMI 34.0 ± 3.2; 32.2 ± 4.4 years) participated and were randomly distributed into three groups: (1) Intermittent fasting combined with exercise group (IF + EX); (2) Exercise group (EX); and (3) Intermittent fasting group (IF). The interventions took place over 8 weeks and all evaluations were performed pre and post-intervention. The HIIT circuit was performed 3x/week, for 25 mins/session, at 70–85% of the maximum heart rate. The intermittent fasting protocol was a 5:2 diet with two meals within 6 h on fasting days, being 25% of total energy intake, plus 18 h of complete fasting. The protocol was performed 2x/week and 5 days of ad libitum ingestion. Resting metabolic rate (RMR) was measured by indirect calorimetry, body composition by BodPod®, NB from urinary nitrogen, food consumption by food records and physical and strength performance were measured by physical tests. ANOVA two-way repeated measures mixed model was performed followed by Sidak post hoc (p < 0.05). This project was registered in ClinicalTrials.gov, NCT05237154.ResultsThere were a reduction in body weight (P = 0.012) and BMI (P = 0.031) only in the IF + EX group. There was body fat loss in the IF + EX group (−4%, P < 0.001) and in the EX group (−2.3%, P = 0.043), an increase in fat-free mass in the IF + EX group (+3.3%, P < 0.001) and also in the EX group (+2%, P = 0.043), without differences between groups and the IF group showed no changes. The NB was equilibrium in all groups. All parameters of aerobic capacity and strength improved.ConclusionCombining IF with HIIT can promote increments in fat-free mass, NB equilibrium and improve physical fitness and strength.
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Affiliation(s)
- Gabriela Batitucci
- Department of Food and Nutrition, School of Pharmaceutical Sciences of Araraquara, State University of São Paulo - FCFAR/UNESP, Araraquara, Brazil
| | - Eli V. Faria Junior
- Department of Health Sciences, Ribeirão Preto Medical School, University of São Paulo - FMRP/USP, Ribeirão Preto, Brazil
| | - Jonatas E. Nogueira
- Laboratory of Exercise Physiology and Metabolism, School of Physical Education and Sports of Ribeirão Preto, University of São Paulo - EEFERP/USP, Ribeirão Preto, Brazil
| | - Camila F. C. Brandão
- Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Gabriela F. Abud
- Department of Food and Nutrition, School of Pharmaceutical Sciences of Araraquara, State University of São Paulo - FCFAR/UNESP, Araraquara, Brazil
| | - Gabriela U. Ortiz
- Department of Health Sciences, Ribeirão Preto Medical School, University of São Paulo - FMRP/USP, Ribeirão Preto, Brazil
| | - Julio S. Marchini
- Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ellen C. Freitas
- Department of Food and Nutrition, School of Pharmaceutical Sciences of Araraquara, State University of São Paulo - FCFAR/UNESP, Araraquara, Brazil
- Department of Health Sciences, Ribeirão Preto Medical School, University of São Paulo - FMRP/USP, Ribeirão Preto, Brazil
- Laboratory of Exercise Physiology and Metabolism, School of Physical Education and Sports of Ribeirão Preto, University of São Paulo - EEFERP/USP, Ribeirão Preto, Brazil
- *Correspondence: Ellen C. Freitas,
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Guiding the formulation of soft cereal foods for the elderly population through food oral processing: Challenges and opportunities. ADVANCES IN FOOD AND NUTRITION RESEARCH 2022; 99:137-188. [PMID: 35595393 DOI: 10.1016/bs.afnr.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
As the elderly population is growing steadily, more age-friendly food products that allow them to cover their nutritional needs and are enjoyable need to be designed. Since their oral physiology is considerably altered, the study of Food Oral Processing has become an essential discipline in food development, as it takes into consideration the complex interactions between food structure, oral processing, physiology and perception. Cereals are staple foods in many countries, and their consumption as bakery products is popular among the elderly population. In addition, when fortified with pulse proteins, they can help meet the protein needs of seniors and help fight against sarcopenia. For these reasons, this chapter presents an overview of the various aspects involved in the oral processing and formulation of soft cereal foods, translating them into challenges and opportunities that are of relevance to the design of realistic soft cereal foods targeted for the elderly that are nutritious and sensory appealing. This review focuses on the healthy elderly population and does not intend to cover the needs of the dependent elderly suffering from chronical diseases.
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Maha M, Sohail S, R. IM, Wael MES. Assessment of the antifertility effects of some plants in male albino mice. SCIENTIFIC RESEARCH AND ESSAYS 2021; 16:58-63. [DOI: 10.5897/sre2021.6734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/09/2023]
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13
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Assessing calorie and protein recommendations for survivors of critical illness weaning from prolonged mechanical ventilation - can we find a proper balance? Clin Nutr ESPEN 2021; 45:449-453. [PMID: 34620353 PMCID: PMC8925994 DOI: 10.1016/j.clnesp.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/04/2021] [Indexed: 12/07/2022]
Abstract
Background & aims: Survivors of critical illness requiring prolonged mechanical ventilation (PMV) are predisposed to malnutrition, muscle wasting, and weakness. There is a lack of data regarding nutrition adequacy among these patients, and although nitrogen balance has been studied as a marker of adequate protein intake in healthy individuals and acutely critically ill patients, it has not been well studied in critically ill patients with PMV. The purpose of this study was to determine if patients requiring PMV admitted to a long-term acute care hospital (LTACH) achieved registered dietitian (RD) recommended goals for energy and protein intake and if the recommendations were adequate to avoid negative nitrogen balance. Methods: Using a retrospective, cohort study design, patients requiring PMV who had orders for 24-h urine collections for urea nitrogen (24hrUUN) were included. Energy and protein intake was calculated from chart documentation of dietary intake for the 24-h period during which patients underwent a 24hrUUN. Nitrogen intake was estimated from protein intake. Dietary intake was compared to RD-recommendations to determine the percentage of RD-recommendations achieved. Nitrogen balance was calculated as nitrogen intake minus nitrogen loss, with negative balance categorized as less than −1. Results: Subjects (n = 16) were 38% male and 75% African American (mean age 61.5 ± 3.2 years; mean BMI 27.5 ± 2.5 kg/m2). Duration of LTACH hospitalization was 26.5 (6–221) days. Mean energy and protein intake was 21.7 ± 2.9 kcal/kg/d and 1.1 ± 0.1 g/kg/d, respectively, which corresponded to 86% of both RD energy and protein recommendations. Ten patients achieved a positive nitrogen balance (mean 0.9 ± 1.1 g). In addition, there was a positive linear relationship between protein intake and nitrogen balance (r = 0.59, p = 0.016). Conclusion: Survivors of critical illness requiring PMV achieved a high percentage of RD-recommended protein and calories, and prevented a negative nitrogen balance in a majority of patients. Increasing protein intake can prevent a negative nitrogen balance. Future studies should evaluate whether these patients are able to maintain a steady state of nitrogen intake and excretion over time and how this affects time to and/or success of weaning.
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Buckley CT, Prasanna N, Mays AL, Tinsley JM, Dickerson RN. Protein requirements for critically ill ventilator-dependent patients with COVID-19. Nutr Clin Pract 2021; 36:984-992. [PMID: 34468046 PMCID: PMC8662189 DOI: 10.1002/ncp.10763] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Recent studies indicate critically ill patients with coronavirus disease 2019 (COVID‐19) are hypermetabolic; however, protein requirements in critically ill COVID‐19 patients are unknown. Our intent was to evaluate the nitrogen accretion response to varying protein intakes for critically ill ventilator‐dependent patients with COVID‐19. Methods Adult patients (age ≥ 18 years) with COVID‐19, admitted to the intensive care unit (ICU) and who required mechanical ventilation were retrospectively evaluated. Patients received continuous enteral nutrition (EN), including supplemental protein boluses, and had a 24‐h urine collection for determination of nitrogen balance (NBAL). Data are expressed as mean ± SD with a P‐value < .05 as significant. Results Twenty‐two patients provided 29 NBAL determinations. Protein intake from EN and protein supplements was 0.9 ± 0.7 g/kg/day at the time of the NBAL with an NBAL of –12.1 ± 10.9 g/day at 7 ± 4 days in the ICU. Combined caloric intake from EN and propofol at the time of the NBAL was 12 ± 8 kcal/kg/day. Nitrogen equilibrium (NBAL of –4 g/day or better) occurred in five patients. Patients achieving nitrogen equilibrium received more protein than those with a negative NBAL (1.2 ± 0.4 g/kg/day vs 0.8 ± 0.8 g/kg/day, P = .046). The linear regression for NBAL in response to graded increases in protein intake was as follows: NBAL = 8.5 × protein intake (g/kg/day) – 18.8 (r = 0.450, P < .001). Conclusion Critically ill ventilator‐dependent patients with COVID‐19 exhibit significant variability in nitrogen accretion response to increases in protein intake and often have a markedly negative NBAL.
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Affiliation(s)
- Christopher T Buckley
- Department of Pharmacy Practice, Union University, College of Pharmacy, Jackson, Tennessee, USA
| | - Nivedita Prasanna
- Department of Critical Care Medicine, Jackson-Madison County General Hospital, Jackson, Tennessee, USA
| | - Abby L Mays
- Department of Nutrition, Jackson-Madison County General Hospital, Jackson, Tennessee, USA
| | - Jeanette M Tinsley
- Department of Nutrition, Jackson-Madison County General Hospital, Jackson, Tennessee, USA
| | - Roland N Dickerson
- Department of Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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15
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Impact of β-hydroxy-β-methylbutyrate (HMB) on muscle loss and protein metabolism in critically ill patients: A RCT. Clin Nutr 2021; 40:4878-4887. [PMID: 34358832 DOI: 10.1016/j.clnu.2021.07.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Muscle wasting deteriorates life quality after critical illness and increases mortality. Wasting starts upon admission to intensive care unit (ICU). We aimed to determine whether β-hydroxy-β-methylbutyrate (HMB), a metabolite of leucine, can attenuate this process. METHODS Prospective randomized, placebo-controlled double blind trial. INCLUSION CRITERIA ICU patients depending on mechanical ventilation on day 3 having a functional gastrointestinal tract. They were randomized to HMB (3 g/day) or placebo (maltodextrin) from day 4 on for 30 days. PRIMARY OUTCOME magnitude of loss of skeletal muscle area (SMA) of the quadriceps femoris measured by ultrasound at days 4 and 15. SECONDARY OUTCOMES body composition, change in protein metabolism assessed by amino acids tracer pulse, and global health at 60 days. Data are mean [95% CI]. Statistics by ANCOVA with correction for confounders sex, age and/or BMI. RESULTS Thirty patients completed the trial, aged 65 [59, 71] years, SAPS2 score 48 [43, 52] and SOFA 8.5 [7.4, 9.7]. The loss of total SMA was 11% between days 4 and 15 (p < 0.001), but not different between the groups (p = 0.86). In the HMB group, net protein breakdown (Δ Estimate HMB-Placebo: -153 [-242, -63]; p = 0.0021) and production of several amino acid was significantly reduced, while phase angle increased more (0.66 [0.09, 1.24]; p = 0.0247), and SF-12 global health improved more (Δ Estimate HMB-Placebo: 27.39 [1.594, 53.19], p = 0.04). CONCLUSION HMB treatment did not significantly reduce muscle wasting over 10 days of observation (primary endpoint), but resulted in significantly improved amino acid metabolism, reduced net protein breakdown, a higher phase angle and better global health. CLINICALTRIALS. GOV IDENTIFIER NCT03628365.
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16
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Lakenman PLM, van der Hoven B, Schuijs JM, Eveleens RD, van Bommel J, Olieman JF, Joosten KFM. Energy expenditure and feeding practices and tolerance during the acute and late phase of critically ill COVID-19 patients. Clin Nutr ESPEN 2021; 43:383-389. [PMID: 34024544 PMCID: PMC8016730 DOI: 10.1016/j.clnesp.2021.03.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Different metabolic phases can be distinguished in critical illness, which influences nutritional treatment. Achieving optimal nutritional treatment during these phases in critically ill patients is challenging. COVID-19 patients seem particularly difficult to feed due to gastrointestinal problems. Our aim was to describe measured resting energy expenditure (mREE) and feeding practices and tolerance during the acute and late phases of critical illness in COVID-19 patients. METHODS Observational study including critically ill mechanically ventilated adult COVID-19 patients. Indirect calorimetry (Q-NRG+, Cosmed) was used to determine mREE during the acute (day 0-7) and late phase (>day 7) of critical illness. Data on nutritional intake, feeding tolerance and urinary nitrogen loss were collected simultaneously. A paired sample t-test was performed for mREE in both phases. RESULTS We enrolled 21 patients with a median age of 59 years [44-66], 67% male and median BMI of 31.5 kg/m2 [25.7-37.8]. Patients were predominantly fed with EN in both phases. No significant difference in mREE was observed between phases (p = 0.529). Sixty-five percent of the patients were hypermetabolic in both phases. Median delivery of energy as percentage of mREE was higher in the late phase (94%) compared to the acute phase (70%) (p = 0.001). Urinary nitrogen losses were significant higher in the late phase (p = 0.003). CONCLUSION In both the acute and late phase, the majority of the patients were hypermetabolic and fed enterally. In the acute phase patients were fed hypocaloric whereas in the late phase this was almost normocaloric, conform ESPEN guidelines. No significant difference in mREE was observed between phases. Hypermetabolism in both phases in conjunction with an increasing loss of urinary nitrogen may indicate that COVID-19 patients remain in a prolonged acute, catabolic phase.
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Affiliation(s)
- P L M Lakenman
- Division of Dietetics, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.
| | - B van der Hoven
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.
| | - J M Schuijs
- Division of Dietetics, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands; Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - R D Eveleens
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - J van Bommel
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - J F Olieman
- Division of Dietetics, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - K F M Joosten
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
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Tavarez T, Roehl K, Koffman L. Nutrition in the Neurocritical Care Unit: a New Frontier. Curr Treat Options Neurol 2021; 23:16. [PMID: 33814896 PMCID: PMC8009929 DOI: 10.1007/s11940-021-00670-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW This review presents the most current recommendations for providing nutrition to the neurocritical care population. This includes updates on initiation of feeding, immunonutrition, and metabolic substrates including ketogenic diet, cerebral microdialysis (CMD) monitoring, and the microbiome. RECENT FINDINGS Little evidence exists to support differences in feeding practices among the neurocritical care population. New areas of interest with limited data include use of immunonutrition, pre/probiotics for microbiome manipulation, ketogenic diet, and use of CMD catheters for substrate utilization monitoring. SUMMARY Acute neurologic injury incites a cascade of adrenergic and neuroendocrine events resulting in a pro-inflammatory and hypercatabolic state, which is associated with an increase in morbidity and mortality. Nutritional support provides substrates to mitigate the damaging effects of hypermetabolism. Despite this practice, studies on feeding delivery outcomes remain inconsistent. Guidelines suggest use of early enteral nutrition using standard polymeric formulas. Population heterogeneity, variability in interventions, complexities of the metabolic and inflammatory responses, and paucity of nutrition research in patients requiring neurocritical care have led to controversies in the field. It is imperative that more pragmatic and reproducible research be conducted to better understand underlying pathophysiology and develop interventions that may improve outcomes.
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Affiliation(s)
- Tachira Tavarez
- Department of Neurologic Sciences, Rush University Medical Center, 1725 West Harrison Street Professional Office Building, Suite 1106, Chicago, IL USA
| | - Kelly Roehl
- Department of Food and Nutrition, Rush University Medical Center, Chicago, IL USA
| | - Lauren Koffman
- Department of Neurologic Sciences, Rush University Medical Center, 1725 West Harrison Street Professional Office Building, Suite 1106, Chicago, IL USA
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Wappel S, Tran DH, Wells CL, Verceles AC. The Effect of High Protein and Mobility-Based Rehabilitation on Clinical Outcomes in Survivors of Critical Illness. Respir Care 2021; 66:73-78. [PMID: 32817444 PMCID: PMC8208101 DOI: 10.4187/respcare.07840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Protein supplementation and mobility-based rehabilitation programs (MRP) individually improve functional outcomes in survivors of critical illness. We hypothesized that combining MRP therapy with high protein supplementation is associated with greater weaning success from prolonged mechanical ventilation (PMV) and increased discharge home in this population. METHODS We conducted a retrospective analysis assessing the effects of an MRP on a cohort of survivors of critical illness. All received usual care (UC) rehabilitation. The MRP group received 3 additional MRP sessions each week for a maximum of 8 weeks. Subjects were prescribed nutrition and classified as receiving high protein (HPRO) or low protein (LPRO), based on a recommended 1.0 g/kg/d, and then the subjects were categorized into 4 groups: MRP+HPRO, MRP+LPRO, UC+HPRO, and UC+LPRO. RESULTS A total of 32 subjects were enrolled. The MRP+HPRO group had greater weaning success (90% vs 38%, P = .045) and a higher rate of discharge home (70% vs 13%, P = .037) compared to UC+LPRO group. The MRP+HPRO group had a higher, nonsignificant rate of discharge home compared to the MRP+LPRO (70% vs 20%, P = .10). CONCLUSIONS Combining high protein with mobility-based rehabilitation was associated with increased rates of discharge home and ventilator weaning success in survivors of critical illness. Further studies are needed to evaluate the role of combined exercise and nutrition interventions in this population.
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Affiliation(s)
- Stephanie Wappel
- Department of Pulmonary, Critical Care and Sleep Medicine, Greater Baltimore Medical Center, Towson, Maryland
| | - Dena H Tran
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, Maryland
| | - Chris L Wells
- Department of Physical Therapy, University of Maryland Medical Center, Baltimore, Maryland
| | - Avelino C Verceles
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland.
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PÉRSICO RS, SOUZA GC, FRANZOSI OS, ROVATI BDAR, SANTOS ZEDA. Nitrogen balance in mechanically ventilated obese patients. REV NUTR 2021. [DOI: 10.1590/1678-9865202134e190263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Objective This study aimed to evaluate if the protein intake recommendations for obese critically ill requiring mechanical ventilation are sufficient to promote a positive or neutral nitrogen balance. Methods Cross-sectional study that included 25 obese, ≥18 years old, undergoing mechanical ventilation and who were target to receive high-protein enteral nutrition therapy (2.0-2.5g/kg ideal body weight). Clinical, nutritional and biochemical variables were analyzed. Nitrogen balance was performed when patient was receiving full enteral nutrition therapy and was classified: positive when intake was greater than excretion; negative when excretion was greater than intake; neutral when both were equal. Results The characteristics of patients evaluated were 64.1±9.4 years old, clinical treatment 88%, body mass index 36.5±5.1kg/m2, nitrogen balance 0.3g/day (-5.3 to 4.8g/day), protein intake 2.1g/day (2.0-2.3g/kg) ideal body weight. Of individuals analyzed, 52% showed positive or neutral nitrogen balance with median of 4.23g/day 2.41 to 6.40g/day) in comparison to negative group with median of -5.27g/day (-10.38 to -3.86g/day). Adults had higher ratio of negative nitrogen balance (57.1%) than elderly (44.4%), with protein intake of 2.0 versus 2.1g/day, respectively. No correlation was found between nitrogen balance and variables assessed. Conclusion High-protein enteral nutrition therapy contributed to positive or neutral nitrogen balance for approximately half of obese ventilated individuals. With similar protein intake, elderly showed a higher proportion of positive or neutral nitrogen balance. Nitrogen balance can be influenced by various factors, so further studies are required to identify different protein needs in obese critically.
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Dietary Intake and Nitrogen Balance in British Army Infantry Recruits Undergoing Basic Training. Nutrients 2020; 12:nu12072125. [PMID: 32709021 PMCID: PMC7400853 DOI: 10.3390/nu12072125] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/12/2020] [Accepted: 07/15/2020] [Indexed: 12/21/2022] Open
Abstract
We assessed dietary intake and nitrogen balance during 14 weeks of Basic Training (BT) in British Army Infantry recruits. Nineteen men (mean ± SD: age 19.9 ± 2.6 years, height: 175.7 ± 6.5 cm, body mass 80.3 ± 10.1 kg) at the Infantry Training Centre, Catterick (ITC(C)) volunteered. Nutrient intakes and 24-h urinary nitrogen balance were assessed in weeks 2, 6 and 11 of BT. Nutrient intake was assessed using researcher-led weighed food records and food diaries, and Nutritics professional dietary software. Data were compared between weeks using a repeated-measures analysis of variance (ANOVA) with statistical significance set at p ≤ 0.05. There was a significant difference in protein intake (g) between weeks 2 and 11 of BT (115 ± 18 vs. 91 ± 20 g, p = 0.02, ES = 1.26). There was no significant difference in mean absolute daily energy (p = 0.44), fat (p = 0.79) or carbohydrate (CHO) intake (p = 0.06) between weeks. Nitrogen balance was maintained in weeks 2, 6 and 11, but declined throughout BT (2: 4.6 ± 4.1 g, 6: 1.6 ± 4.5 g, 11: -0.2 ± 5.5 g, p = 0.07). A protein intake of 1.5 g·kg-1·d-1 may be sufficient in the early stages of BT, but higher intakes may be individually needed later on in BT.
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Dickerson RN. Protein Requirements during Hypocaloric Nutrition for the Older Patient With Critical Illness and Obesity: An Approach to Clinical Practice. Nutr Clin Pract 2020; 35:617-626. [PMID: 32588488 DOI: 10.1002/ncp.10501] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Current guidelines recommend a hypocaloric, high protein nutrition regimen for patients with obesity and critical illness. The impact of advancing age presents with unique challenges in which a greater protein intake is required to overcome the anabolic resistance associated with aging in the face of presumed decreased renal function. The primary objective of this review is to provide an overview of the impact of obesity and advancing age on protein requirements for patients with critical illness and review the scientific evidence supporting the rationale for hypocaloric, high protein nutrition for this subpopulation, as well as provide some practical suggestions for their clinical management.
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Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, Tennessee, USA
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Iacone R, Scanzano C, Santarpia L, Cioffi I, Contaldo F, Pasanisi F. Macronutrients in Parenteral Nutrition: Amino Acids. Nutrients 2020; 12:E772. [PMID: 32183395 PMCID: PMC7146427 DOI: 10.3390/nu12030772] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 12/12/2022] Open
Abstract
The right amount and quality of amino acids (AAs) supplied to patients on parenteral nutrition (PN) reduces muscle mass loss, may preserve or even increase it, with significant clinical benefits. Several industrial PN mixtures are available so that nutrition specialists can choose the product closest to the patient's needs. In selected cases, there is the possibility of personalizing compounded mixtures in a hospital pharmacy that completely meets the individual nutritional needs of PN patients. This narrative review deals with the AA solutions used in PN mixtures. The physiology, the methods to calculate the AA needs, and the AA and energy requirements suggested by scientific guidelines for each patient type are also reported.
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Affiliation(s)
- Roberto Iacone
- Clinical Nutrition Unit, Department of Clinical Medicine and Surgery Federico II University Hospital, 80131 Naples, Italy; (C.S.); (L.S.); (I.C.); (F.C.); (F.P.)
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23
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Seifi N, Safarian M, Nematy M, Rezvani R, Khadem-Rezaian M, Sedaghat A. Effects of synbiotic supplementation on energy and macronutrients homeostasis and muscle wasting of critical care patients: study protocol and a review of previous studies. Trials 2020; 21:221. [PMID: 32093741 PMCID: PMC7041281 DOI: 10.1186/s13063-020-4136-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 02/03/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND An extreme and persistent dysbiosis occurs among critically ill patients, regardless of the heterogeneity of disease. Dysbiosis in critically ill patients may make them prone to hospital-acquired infections, sepsis, multi-organ failure (MOF), energy homeostasis disturbance, muscle wasting, and cachexia. Modulation of gut microbiota through synbiotics can be considered as a potential treatment for muscle wasting and macronutrient homeostasis disturbances. METHODS This is a prospective, single-center, double-blind, parallel randomized controlled trial with the aim to evaluate the effects of synbiotic supplementation on energy and macronutrient homeostasis and muscle wasting in critically ill patients. A total of 40 hemodynamically stable, adult, critically ill patients who receive enteral nutrition via a nasogasteric tube (NGT) in the 24-48 h after admission to critical care will be included in this study. Eligible patients will be randomly assigned to receive Lactocare (ZistTakhmir) capsules 500 mg every 12 h or a placebo capsule, which contains only the sterile maize starch and is similar to synbiotic capsules for 14 days. The synbiotic and placebo capsules will be given through the nasogastric tube, separately from gavage, after feeding. DISCUSSION Gut microbiota modulation through synbiotics is proposed to improve clinical prognosis and reduce infectious complications, ventilator dependency, and length of ICU stay by improving energy and macronutrient homeostasis and reducing muscle protein catabolism. TRIAL REGISTRATION Iranian Registry of Clinical Trials, IRCT20190227042857N1. Registered on 17 March 2019.
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Affiliation(s)
- Najmeh Seifi
- Department of Nutrition, Medical School, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Safarian
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohsen Nematy
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Rezvani
- Department of Nutrition, Medical School, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Majid Khadem-Rezaian
- Department of community medicine, Medical School, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Sedaghat
- Department of Anesthesiology, Mashhad University of Medical Sciences, Mashhad, Iran.
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24
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Liu C, Hu N, Song W, Chen Q, Zhu L. Aquaculture Feeds Can Be Outlaws for Eutrophication When Hidden in Rice Fields? A Case Study in Qianjiang, China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16224471. [PMID: 31766308 PMCID: PMC6887982 DOI: 10.3390/ijerph16224471] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 11/07/2019] [Accepted: 11/09/2019] [Indexed: 11/16/2022]
Abstract
Water eutrophication caused by agricultural production has become one of the most important factors that impede sustainable rural environmental governance in China. As a result, the Chinese central and local governments want to reduce the use of nitrogen and phosphorus fertilizer and gain socioeconomical profit simultaneously by promoting crayfish and rice integrated system (CRIS) in the rural areas with abundant water resources. In this article, we investigated whether CRIS in Qianjiang, Hubei, the origin place of the system in China, contributes to fulfilling the governments’ expectations. We found that CRIS efficaciously cuts the fertilizer rate in rice production and boosts farmers’ incomes because crayfish has a demand for water quality and holds a large internal market requirement. However, higher profit encourages farmers to expand crayfish production and thus discourages the initiatives in rice production. The area of the ditch for crayfish production expands ceaselessly and exceeds the limit of regulation of CRIS. As a result, the CRIS in the areas has emerged as a practice of aquaculture but in farmland. This is a regulatory gap. The input–output analysis of CRIS by material balance method can also reveal that excessive feed for crayfish has become a new source of agricultural pollution. Beyond that, due to the changed irrigation system and increased water exchange frequency of CRIS, the pollution has transformed from passive distribution to active, which will increase the risk of water eutrophication on a large area.
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Affiliation(s)
- Chunhui Liu
- College of Humanities & Social Development, Nanjing Agricultural University, Nanjing 210095, China; (C.L.); (N.H.); (Q.C.)
- Institute of Regional Agricultural Research, Nanjing Agricultural University, Nanjing 210095, China
| | - Naijuan Hu
- College of Humanities & Social Development, Nanjing Agricultural University, Nanjing 210095, China; (C.L.); (N.H.); (Q.C.)
- Institute of Regional Agricultural Research, Nanjing Agricultural University, Nanjing 210095, China
| | - Weixuan Song
- Nanjing Institute of Geography and Limnology, Chinese Academy of Sciences, Nanjing 210008, China;
- Key Laboratory of Watershed Geographic Sciences, Chinese Academy of Sciences, Nanjing 210008, China
| | - Qian Chen
- College of Humanities & Social Development, Nanjing Agricultural University, Nanjing 210095, China; (C.L.); (N.H.); (Q.C.)
- Institute of Regional Agricultural Research, Nanjing Agricultural University, Nanjing 210095, China
| | - Liqun Zhu
- College of Humanities & Social Development, Nanjing Agricultural University, Nanjing 210095, China; (C.L.); (N.H.); (Q.C.)
- Institute of Regional Agricultural Research, Nanjing Agricultural University, Nanjing 210095, China
- Correspondence: ; Tel.: +86-25-84396365
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25
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Danielis M, Lorenzoni G, Azzolina D, Iacobucci A, Trombini O, De Monte A, Gregori D, Beltrame F. Effect of Protein-Fortified Diet on Nitrogen Balance in Critically Ill Patients: Results from the OPINiB Trial. Nutrients 2019; 11:E972. [PMID: 31035354 PMCID: PMC6567073 DOI: 10.3390/nu11050972] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 12/25/2022] Open
Abstract
Nitrogen balance (NB) is considered a good marker of adequate protein intake and it has been suggested to be a good predictor of patients' health outcomes. However, in literature, there is a lack of large randomized trials examining NB-guided protein intake in patients in intensive care units (ICUs). A randomized controlled trial enrolling patients admitted to ICU was done to compare changes in NB. Participants were randomized to a standard or protein-fortified diet (protein intake of 1.8 g/kg/day according to the guidelines of the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition). The primary endpoint was represented by the NB on Day 1, 3, and study exit. Forty patients were enrolled in the study (19 in the protein-fortified group). The longitudinal analysis showed that, on Day 3, patients randomized to the protein-fortified diet were more likely (p < 0.001) to present better NB (at 3 days, patients in the protein-fortified diet were estimated to have a nitrate value of 5.22 g more than patients in the standard diet, 95% CI 3.86-6.58). The protein-fortified diet was found to be significantly and directly associated with changes in NB in critically ill patients admitted to ICU.
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Affiliation(s)
- Matteo Danielis
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata di Udine, Udine 33100, Italy.
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova 35131, Italy.
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova 35131, Italy.
| | - Anna Iacobucci
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata di Udine, Udine 33100, Italy.
| | - Omar Trombini
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata di Udine, Udine 33100, Italy.
| | - Amato De Monte
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata di Udine, Udine 33100, Italy.
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova 35131, Italy.
| | - Fabio Beltrame
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata di Udine, Udine 33100, Italy.
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26
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Reckman GAR, Gomes-Neto AW, Vonk RJ, Ottery FD, van der Schans CP, Navis GJ, Jager-Wittenaar H. Anabolic competence: Assessment and integration of the multimodality interventional approach in disease-related malnutrition. Nutrition 2019; 65:179-184. [PMID: 31170682 DOI: 10.1016/j.nut.2019.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 02/06/2019] [Accepted: 03/20/2019] [Indexed: 01/04/2023]
Abstract
Disease-related malnutrition (DRM) is a frequent clinical problem, characterized by loss of lean body mass and decreased function, including muscle function and immunocompetence. In DRM, nutritional intervention is necessary, but it has not consistently been shown to be sufficient. Other factors, for example, physical activity and hormonal or metabolic influencers of the internal milieu, are also important in the treatment of DRM. A prerequisite for successful treatment of DRM is the positive balance between anabolism and catabolism. The aim of this review was to approach DRM using this paradigm of anabolic competence, for conceptual and practical reasons. Anabolic competence is defined as "that state which optimally supports protein synthesis and lean body mass, global aspects of muscle and organ function, and immune response." Anabolic competence and interdisciplinary, multimodality interventions create a practical foundation to approach DRM in a proactive comprehensive way. Here, we describe the paradigm of anabolic competence, and its operationalization by measuring factors related to anabolic competence and suited for clinical management of patients with DRM.
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Affiliation(s)
- G A R Reckman
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands
| | - A W Gomes-Neto
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R J Vonk
- Department Cell Biology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - F D Ottery
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands; Ottery & Associates, LLC, Oncology Care Consultants, Deerfield, Chicago, Illinois, USA
| | - C P van der Schans
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands; Rehabilitation and Health Psychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - G J Navis
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - H Jager-Wittenaar
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands; Department of Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Abstract
Inflammation is an adaptive process to the noxious stimuli that the human body is constantly exposed to. From the local inflammatory response to a full-blown systemic inflammation, a wide complex sequence of events occurs. Persistent immunosuppression and catabolism may ensue, until multiple organ failure finally sets in. And since clinically useful and specific biomarkers are lacking, diagnosis may come late. A thorough understanding of these events (how they begin, how they evolve, and how to modulate them) is imperative, but as yet poorly studied. This review aims to consolidate current knowledge of these events so that the management of these patients is not only evidence-based, but also built on an understanding of the inner workings of the human body in health and in disease.
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Affiliation(s)
- Miguel Lourenço Varela
- Internal Medicine 1, Hospital de Faro, Centro Hospitalar Universitário do Algarve, Rua Leão Penedo, Faro, 8000-386, Portugal.
- Intensive Care Medicine 1, Hospital de Faro, Centro Hospitalar Universitário do Algarve, Rua Leão Penedo, Faro, 8000-386, Portugal.
| | - Mihail Mogildea
- Internal Medicine 1, Hospital de Faro, Centro Hospitalar Universitário do Algarve, Rua Leão Penedo, Faro, 8000-386, Portugal
| | - Ignacio Moreno
- Internal Medicine 1, Hospital de Faro, Centro Hospitalar Universitário do Algarve, Rua Leão Penedo, Faro, 8000-386, Portugal
| | - Ana Lopes
- Internal Medicine 1, Hospital de Faro, Centro Hospitalar Universitário do Algarve, Rua Leão Penedo, Faro, 8000-386, Portugal
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28
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Preiser JC. High protein intake during the early phase of critical illness: yes or no? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:261. [PMID: 30360760 PMCID: PMC6203200 DOI: 10.1186/s13054-018-2196-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/19/2018] [Indexed: 11/10/2022]
Abstract
The rationale for the provision of nitrogen from proteins given via the enteral route or from intravenous amino acids is to boost the synthesis of muscle proteins, and thereby to limit the severity of intensive care unit-acquired weakness by the prevention of muscle loss. However, the optimal timing for supplemental nitrogen provision is a matter of debate and controversy. Indeed, consistent data from retrospective studies support an association between high early protein intakes and better outcomes, while recent post-hoc findings from prospective studies raise safety concerns. This pro–con paper details the arguments of both sides and highlights the need for large-scale prospective studies assessing the safety and efficacy of different levels of protein intake in combination with physical activity and summarizes the currently recruiting clinical trials.
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Affiliation(s)
- Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, 808 route de Lennik, B-1070, Brussels, Belgium.
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29
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Dickerson RN. Metabolic support challenges with obesity during critical illness. Nutrition 2018; 57:24-31. [PMID: 30153576 DOI: 10.1016/j.nut.2018.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/14/2018] [Accepted: 05/21/2018] [Indexed: 12/21/2022]
Abstract
Adiposity-based chronic disease, critical illness, and nutrition therapy increase the risk for overfeeding and worsened nutritional and clinical outcomes. Hypocaloric, high-protein nutrition therapy provides critically ill obese patients the opportunity to achieve net protein anabolism with a reduced risk for overfeeding-related complications. The intent of this review is to discuss the impact of obesity on clinical outcomes, describe the consequences of obesity that increase complications associated with nutrition therapy, provide the framework to develop a hypocaloric, high-protein regimen, review the scientific evidence to support this mode of therapy, and discuss its limitations. Practical suggestions for patient monitoring are also provided.
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Affiliation(s)
- Roland N Dickerson
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee.
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30
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Hoffer LJ. High-Protein Hypocaloric Nutrition for Non-Obese Critically Ill Patients. Nutr Clin Pract 2018; 33:325-332. [PMID: 29701916 DOI: 10.1002/ncp.10091] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
High-protein hypocaloric nutrition, tailored to each patient's muscle mass, protein-catabolic severity, and exogenous energy tolerance, is the most plausible nutrition therapy in protein-catabolic critical illness. Sufficient protein provision could mitigate the rapid muscle atrophy characteristic of this disease while providing urgently needed amino acids to the central protein compartment and sites of tissue injury. The protein dose may range from 1.5 to 2.5 g protein (1.8-3.0 g free amino acids)/kg dry body weight per day. Nutrition should be low in energy (≈70% of energy expenditure or ≈15 kcal/kg dry body weight per day) because efforts to match energy provision to energy expenditure are physiologically irrational, risk toxic energy overfeeding, and have repeatedly failed in large clinical trials to demonstrate clinical benefit. The American Society for Parenteral and Enteral Nutrition currently suggests high-protein hypocaloric nutrition for obese critically ill patients. Short-term high-protein hypocaloric nutrition is physiologically and clinically sensible for most protein-catabolic critically ill patients, whether obese or not.
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Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
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31
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Kuchnia AJ, Teigen L, Nagel E, Ligthart-Melis G, Mulasi U, Weijs P, Earthman CP. Protein in the Hospital: Gaining Perspective and Moving Forward. JPEN J Parenter Enteral Nutr 2018; 42:270-278. [PMID: 29356030 DOI: 10.1002/jpen.1068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/14/2017] [Indexed: 12/15/2022]
Abstract
Provision of adequate protein is crucial for optimizing outcomes in hospitalized patients. However, the methodologies upon which current recommendations are based have limitations, and little is known about true requirements in any clinical population. In this tutorial, we aim to give clinicians an understanding of how current protein recommendations were developed, an appreciation for the limitations of these recommendations, and an overview of more sophisticated approaches that can be applied to better define protein requirements. A broader perspective of the challenges and opportunities in determining clinical protein requirements can help clinicians think critically about the individualized nutrition care they provide to their patients with the goal of administering adequate protein to optimize outcomes.
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Affiliation(s)
- Adam J Kuchnia
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Levi Teigen
- Department of Food Science and Nutrition, University of Minnesota-Twin Cities, Minneapolis, Minnesota, USA
| | - Emily Nagel
- Department of Food Science and Nutrition, University of Minnesota-Twin Cities, Minneapolis, Minnesota, USA
| | - Gerdien Ligthart-Melis
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, College Station, Texas, USA
| | - Urvashi Mulasi
- Department of Family and Consumer Sciences, California State University, Sacramento, California, USA
| | - Peter Weijs
- Department of Nutrition and Dietetics, Faculty of Sports and Nutrition, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Department of Nutrition and Dietetics, Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Carrie P Earthman
- Department of Food Science and Nutrition, University of Minnesota-Twin Cities, Minneapolis, Minnesota, USA
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32
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Aubry E, Aeberhard C, Bally L, Nuoffer JM, Risch L, Mühlebach S, Burgunder JM, Stanga Z. Are patients affected by mitochondrial disorders at nutritional risk? Nutrition 2017; 47:56-62. [PMID: 29429536 DOI: 10.1016/j.nut.2017.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/18/2017] [Accepted: 09/23/2017] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Patients with mitochondrial disorders (MD) frequently present with gastrointestinal complaints, mainly gastrointestinal dysmotility, that interfere with their food intake. A deterioration of their nutritional state may worsen the course of the disease. Our study aimed to evaluate a simple screening tool to identify nutritional risk and perform an extended nutritional assessment to explore the potential presence of deficiencies in this population compared with controls. METHODS A prospective cohort study was conducted to compare outpatients with MD to matched healthy controls. Nutritional screening and full nutritional assessments were performed, including quantitative and qualitative dietary habits (7-d food log), body function and composition, and resting energy expenditure and quality of life (QoL) measurements. Blood and 24-h urine sample analyses were performed in the patient group. RESULTS Twenty-six subjects were included in the study, with 11 in the patient group and 15 in the control group. No patient was deemed malnourished according to the nutritional risk score NRS-2002. When compared with the controls, however, the patients with MD had significantly lower muscle mass (P = 0.04), reduced handgrip strength (P = 0.07), and significant changes in QoL and pathologic creatinine height index, which indicate malnutrition. The patients with MD also had a significantly lower protein intake (P = 0.01). CONCLUSIONS According to the current definition by the European Society of Clinical Nutrition and Metabolism (ESPEN) and the American Society of Parenteral and Enteral Nutrition (ASPEN), all patients fulfilled the criteria for malnutrition. Thus, the usual nutritional screening tool is less sensitive for chronically ill outpatients. These results provide a rationale to increase protein intake and adapt patients' energy stores to improve symptoms and QoL.
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Affiliation(s)
- Emilie Aubry
- Division of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Switzerland
| | - Carla Aeberhard
- Division of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Switzerland.
| | - Lia Bally
- Division of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Switzerland
| | - Jean-Marc Nuoffer
- University Institute of Clinical Chemistry, Bern University Hospital, Bern, Switzerland
| | - Lorenz Risch
- University Institute of Clinical Chemistry, Bern University Hospital, Bern, Switzerland; Division of Clinical Chemistry, Labormedizinisches Zentrum Dr. Risch, Liebefeld b. Bern, Switzerland; Private University of the Principality of Lichtenstein, Triesen, Principality of Liechtenstein
| | - Stefan Mühlebach
- Department of Clinical Pharmacy and Epidemiology, University of Basel, Basel, Switzerland
| | - Jean-Marc Burgunder
- Division of Neurology, Bern University Hospital, University of Bern, Switzerland; Department of Neurology Sichuan University, Chengdu, P.R. China; Central South University, Hunan, P.R. China; Sun Yat Sen University, Guangzhou, P.R. China
| | - Zeno Stanga
- Division of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Switzerland
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33
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Phillips SM. Current Concepts and Unresolved Questions in Dietary Protein Requirements and Supplements in Adults. Front Nutr 2017; 4:13. [PMID: 28534027 PMCID: PMC5420553 DOI: 10.3389/fnut.2017.00013] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 04/18/2017] [Indexed: 12/21/2022] Open
Abstract
Protein needs for otherwise healthy individuals older than 19 years are defined by the recommended dietary allowance (RDA) at 0.80 g protein/kg/day. There is no recommendation in the current RDA for subpopulations of older adults or people in various pathological situations. Despite the lack of a separate recommendation, there exists a growing body of evidence that is strongly suggestive of an increased need and/or benefit for protein in older persons. That is, intakes beyond the RDA are, in older persons, associated with benefits. In addition, a number of catabolic states including critical illness also result in a sharp elevation in the needs for protein and amino acids. An underappreciated issue in protein nutrition is the impact of protein quality on clinically relevant outcomes. The introduction of a new protein scoring system—the digestible indispensable amino acid score (DIAAS)—for protein quality has raised a forgotten awareness of protein quality. The DIAAS, which replaces the protein digestibility-corrected amino acid score (PDCAAS), is based on ileal digestibility of protein and a different test protein than PDCAAS and has values greater than 1.0. The aim of this article is a brief review and summary recommendations for protein nutrition and protein requirements in populations who would benefit from more protein than the RDA. The emphasis of the review is on muscle protein turnover, and there is a discussion of the impact of protein quality, particularly as it applies to commercially available protein sources. The evidence for more optimal protein intakes is considered in light of the potential health risks of consumption of protein at levels greater than the RDA.
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34
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Parker EA, Feinberg TM, Wappel S, Verceles AC. Considerations When Using Predictive Equations to Estimate Energy Needs Among Older, Hospitalized Patients: A Narrative Review. Curr Nutr Rep 2017; 6:102-110. [PMID: 28868211 DOI: 10.1007/s13668-017-0196-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The aim of this narrative review was to summarize the accuracy of predictive equations used to estimate energy expenditure in older, hospitalized adults. More than 50% of patients admitted to intensive care units are older adults. Currently accepted prediction equations used to determine energy intake in the older, hospitalized patient were not specifically developed for the aging population. Rates of multimorbidity, polypharmacy and malnutrition, conditions that influence energy expenditure, are higher in older adults compared to younger adults. For these reasons, current equations may not accurately assess energy needs in this population. As the evidence demonstrating the importance of nutritional supplementation in older, hospitalized adults grows, more accurate energy assessment methods that account for age-related conditions are needed to predict nutritional requirements.
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Affiliation(s)
- Elizabeth A Parker
- Department of Family & Community Medicine, Center for Integrative Medicine, University of Maryland School of Medicine, 520 W. Lombard Street, Baltimore, MD, USA, (410) 706-6189,
| | - Termeh M Feinberg
- Department of Family & Community Medicine, Center for Integrative Medicine, University of Maryland School of Medicine, 520 W. Lombard Street, Baltimore, MD, USA, (410) 706-6173,
| | - Stephanie Wappel
- University of Maryland Medical Center, Pulmonary & Critical Care Medicine, 110 South Paca Street, Baltimore, MD, USA,
| | - Avelino C Verceles
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD, USA, (410) 328-8141,
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35
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Hurt RT, McClave SA, Martindale RG, Ochoa Gautier JB, Coss-Bu JA, Dickerson RN, Heyland DK, Hoffer LJ, Moore FA, Morris CR, Paddon-Jones D, Patel JJ, Phillips SM, Rugeles SJ, Sarav, MD M, Weijs PJM, Wernerman J, Hamilton-Reeves J, McClain CJ, Taylor B. Summary Points and Consensus Recommendations From the International Protein Summit. Nutr Clin Pract 2017; 32:142S-151S. [DOI: 10.1177/0884533617693610] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Ryan T. Hurt
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Stephen A. McClave
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Robert G. Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Juan B. Ochoa Gautier
- Nestlé HealthCare Nutrition, Inc, Florham Park, New Jersey, USA, and the Department of Critical Care Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Jorge A. Coss-Bu
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Roland N. Dickerson
- Department of Clinical Pharmacology, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Daren K. Heyland
- Department of Critical Care Medicine, Queens University, Kingston, Ontario, Canada
| | - L. John Hoffer
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | | | - Claudia R. Morris
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Douglas Paddon-Jones
- School of Health Professions, University of Texas Medical Branch, Galveston, Texas, USA
| | - Jayshil J. Patel
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stuart M. Phillips
- Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Saúl J. Rugeles
- Department of Surgery, Pontificia Universidad Javeriana Medical School, Hospital Universitario San Ignacio, Bogota, Colombia
| | - Menaka Sarav, MD
- Department of Medicine, Northshore University Health System, Evanston, Illinois, USA
| | - Peter J. M. Weijs
- Department of Medicine, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Jan Wernerman
- Department of Clinical Science, Karolinska University, Stockholm, Sweden
| | - Jill Hamilton-Reeves
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Craig J. McClain
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Beth Taylor
- Department of Food and Nutrition, Barnes-Jewish Hospital, St Louis, Missouri, USA
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36
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Hoffer LJ. Parenteral Nutrition: Amino Acids. Nutrients 2017; 9:nu9030257. [PMID: 28287411 PMCID: PMC5372920 DOI: 10.3390/nu9030257] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 02/24/2017] [Accepted: 03/02/2017] [Indexed: 02/07/2023] Open
Abstract
There is growing interest in nutrition therapies that deliver a generous amount of protein, but not a toxic amount of energy, to protein-catabolic critically ill patients. Parenteral amino acids can achieve this goal. This article summarizes the biochemical and nutritional principles that guide parenteral amino acid therapy, explains how parenteral amino acid solutions are formulated, and compares the advantages and disadvantages of different parenteral amino acid products with enterally-delivered whole protein products in the context of protein-catabolic critical illness.
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Martindale RG, Heyland DK, Rugeles SJ, Wernerman J, Weijs PJM, Patel JJ, McClave SA. Protein Kinetics and Metabolic Effects Related to Disease States in the Intensive Care Unit. Nutr Clin Pract 2017; 32:21S-29S. [PMID: 28388373 DOI: 10.1177/0884533617694612] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Evaluating protein kinetics in the critically ill population remains a very difficult task. Heterogeneity in the intensive care unit (ICU) population and wide spectrum of disease processes creates complexity in assessing protein kinetics. Traditionally, protein has been delivered in the context of total energy. Focus on energy delivery has recently come into question, as the importance of supplemental protein in patient outcomes has been shown in several recent trials. The ICU patient is prone to catabolism, immobilization, and impaired immunity, which is a perfect storm for massive loss of lean body tissue with a unidirectional flow of amino acids from muscle to immune tissue for immunoglobulin production, as well as liver for gluconeogenesis and acute phase protein synthesis. The understanding of protein metabolism in the ICU has been recently expanded with the discovery of how the mammalian target of rapamycin complex 1 is regulated. The concept of "anabolic resistance" and identifying the quantity of protein required to overcome this resistance is gaining support among critical care nutrition circles. It appears that a minimum of at least 1.2 g/kg/d with levels up to 2.0 g/kg/d of protein or amino acids appears safe for delivery in the ICU setting and may yield a better clinical outcome.
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Affiliation(s)
- Robert G Martindale
- 1 Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Daren K Heyland
- 2 Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.,3 Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Saúl J Rugeles
- 4 Surgery Department, Pontificia Universidad Javeriana, Medical School, Hospital Universitario San Ignacio, Bogota, Colombia
| | - Jan Wernerman
- 5 Department of Anesthesiology and Intensive Care Medicine, Karolinska University Hospital, Huddinge, Sweden
| | - Peter J M Weijs
- 6 Department of Intensive Care Medicine, Department of Internal Medicine, VU University Medical Center Amsterdam, Amsterdam, the Netherlands.,7 Faculty of Sports and Nutrition, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
| | - Jayshil J Patel
- 8 Division of Pulmonary & Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stephen A McClave
- 9 Department of Medicine, University of Louisville, Louisville, Kentucky, USA
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38
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Hoffer LJ, Dickerson RN, Martindale RG, McClave SA, Ochoa Gautier JB. Will We Ever Agree on Protein Requirements in the Intensive Care Unit? Nutr Clin Pract 2017; 32:94S-100S. [PMID: 28388370 DOI: 10.1177/0884533617694613] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The precise value of the normal adult protein requirement has long been debated. For many reasons-one of them being the difficulty of carrying out long-term nutrition experiments in free-living people-uncertainty is likely to persist indefinitely. By contrast, the controlled environment of the intensive care unit and relatively short trajectory of many critical illnesses make it feasible to use hard clinical outcome trials to determine protein requirements for critically ill patients in well-defined clinical situations. This article suggests how the physiological principles that underlie our understanding of normal protein requirements can be incorporated into the design of such clinical trials. The main focus is on 3 principles: (1) the rate of body nitrogen loss roughly predicts an individual's minimum protein requirement and is thus essential to measure to identify individual patients and clinical situations in which the minimum protein requirement is importantly increased, (2) existing muscle mass sets an upper limit on the rate at which amino acids can be mobilized from muscle for transfer to central proteins and sites of injury and is thus important to monitor to identify patients who are at greatest risk of protein deficiency-related adverse outcomes, and (3) negative energy balance increases the dietary protein requirement, so calorie-deprived patients-whether obese or not-should be enrolled in hard clinical outcome trials that compare the current practice of "permissive underfeeding" (underprovision of all nutrients, including protein) with hypocaloric nutrition supplemented by a suitably generous amount of protein.
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Affiliation(s)
- L John Hoffer
- 1 Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Roland N Dickerson
- 2 University of Tennessee Health Science Center, Department of Clinical Pharmacy, Memphis, Tennessee, USA
| | - Robert G Martindale
- 3 Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Stephen A McClave
- 4 Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Juan B Ochoa Gautier
- 5 Nestlé HealthCare Nutrition, Inc, Florham Park, New Jersey, USA.,6 Associate Department of Critical Care Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
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39
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Paddon-Jones D, Coss-Bu JA, Morris CR, Phillips SM, Wernerman J. Variation in Protein Origin and Utilization: Research and Clinical Application. Nutr Clin Pract 2017; 32:48S-57S. [PMID: 28388379 DOI: 10.1177/0884533617691244] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Muscle health can be rapidly compromised in clinical environments. Modifiable strategies to preserve metabolic homeostasis in adult patient populations include physical activity and pharmacologic support; however, optimizing dietary practices, or more specifically protein intake, is a necessary prerequisite for any other treatment strategy to be fully effective. Simply increasing protein intake is a well-intentioned but often unfocused strategy to protect muscle health in an intensive care setting. Protein quality is a frequently overlooked factor with the potential to differentially influence health outcomes. Quality can be assessed by a variety of techniques, with digestible indispensable amino acid score being the current and most comprehensive technique endorsed by the Food and Agriculture Organization. In practical terms, animal-based proteins are consistently scored higher in quality compared with incomplete proteins, regardless of the assessment method. Consequently, choosing parenteral and/or enteral feeding options that contain high-quality proteins, rich in the branched-chain amino acid leucine, may help establish a dietary framework with the potential to support clinical practice and improve health outcomes in critically ill patients.
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Affiliation(s)
- Douglas Paddon-Jones
- 1 Department of Nutrition and Metabolism, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Jorge A Coss-Bu
- 2 Pediatrics Critical Care, Baylor College of Medicine, Houston, Texas, USA
| | - Claudia R Morris
- 3 Division of Pediatric Emergency Medicine, Emory School of Medicine, Atlanta, Georgia, USA
| | - Stuart M Phillips
- 4 Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Jan Wernerman
- 5 Department of Clinical Science, Karolinska University, Solna, Sweden
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40
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Dickerson RN, Patel JJ, McClain CJ. Protein and Calorie Requirements Associated With the Presence of Obesity. Nutr Clin Pract 2017; 32:86S-93S. [PMID: 28388369 DOI: 10.1177/0884533617691745] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Obesity compounds the metabolic response to critical illness and increases the risk for overfeeding complications due to its comorbidities. Hypocaloric, high-protein nutrition therapy affords the hospitalized patient with obesity the opportunity to achieve net protein anabolism with a reduced risk of overfeeding complications. The intent of this review is to provide the theoretical framework for development of a hypocaloric high-protein regimen, scientific evidence to support this mode of therapy, and unique considerations for its use in specialized subpopulations. Macronutrient goals and practical suggestions for patient monitoring are given.
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Affiliation(s)
- Roland N Dickerson
- 1 Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee, USA
| | - Jayshil J Patel
- 2 Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Craig J McClain
- 3 Departments of Medicine and Pharmacology & Toxicology, University of Louisville School of Medicine, Louisville, Kentucky, USA
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41
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Phillips SM, Dickerson RN, Moore FA, Paddon-Jones D, Weijs PJM. Protein Turnover and Metabolism in the Elderly Intensive Care Unit Patient. Nutr Clin Pract 2017; 32:112S-120S. [PMID: 28388378 DOI: 10.1177/0884533616686719] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Many intensive care unit (ICU) patients do not achieve target protein intakes particularly in the early days following admittance. This period of iatrogenic protein undernutrition contributes to a rapid loss of lean, in particular muscle, mass in the ICU. The loss of muscle in older (aged >60 years) patients in the ICU may be particularly rapid due to a perfect storm of increased catabolic factors, including systemic inflammation, disuse, protein malnutrition, and reduced anabolic stimuli. This loss of muscle mass has marked consequences. It is likely that the older patient is already experiencing muscle loss due to sarcopenia; however, the period of stay in the ICU represents a greatly accelerated period of muscle loss. Thus, on discharge, the older ICU patient is now on a steeper downward trajectory of muscle loss, more likely to have ICU-acquired muscle weakness, and at risk of becoming sarcopenic and/or frail. One practice that has been shown to have benefit during ICU stays is early ambulation and physical therapy (PT), and it is likely that both are potent stimuli to induce a sensitivity of protein anabolism. Thus, recommendations for the older ICU patient would be provision of at least 1.2-1.5 g protein/kg usual body weight/d, regular and early utilization of ambulation (if possible) and/or PT, and follow-up rehabilitation for the older discharged ICU patient that includes rehabilitation, physical activity, and higher habitual dietary protein to change the trajectory of ICU-mediated muscle mass loss and weakness.
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Affiliation(s)
- Stuart M Phillips
- 1 McMaster University, Department of Kinesiology, Hamilton, Ontario, Canada
| | - Roland N Dickerson
- 2 Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Frederick A Moore
- 3 Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Douglas Paddon-Jones
- 4 Nutrition and Metabolism, University of Texas Medical Branch, Galveston, Texas, USA
| | - Peter J M Weijs
- 5 Nutrition and Dietetics, Department of Internal Medicine, Department of Intensive Care Medicine, and Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands.,6 Nutrition and Dietetics, Faculty of Sports and Nutrition, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
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Abstract
Critically ill people are unable to eat. What’s the best way to feed them? Nutrition authorities have long recommended providing generous amounts of protein and calories to critically ill patients, either intravenously or through feeding tubes, in order to counteract the catabolic state associated with this condition. In practice, however, patients in modern intensive care units are substantially underfed. Several large randomized clinical trials were recently carried out to determine the clinical implications of this situation. Contradicting decades of physiological, clinical, and observational data, the results of these trials have been claimed to justify the current practice of systematic underfeeding in the intensive care unit. This article explains and suggests how to resolve this conundrum.
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Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Bruce R Bistrian
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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