mara lee beebe, ms, rd, ld, cnsc clinical nutrition week highlights january 21-24, 2012 orlando,...
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Mara Lee Beebe, MS, RD, LD, CNSC
Clinical Nutrition Week HighlightsJanuary 21-24, 2012 • Orlando, Florida
Walt Disney World Swan and Dolphin Resort
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Advancing the Science and Practice of Clinical Nutrition and Metabolism for 35 Years
Omega 3 Fatty Acids: History, Metabolism, and FunctionImmune-modulating Enteral Nutrition
Latest Critical Care/ICU ResearchEpanic Trial – early vs late parenteral nutritionPep uP Trial – increase protein and energy in takeIntercept Trial - EPA and GLA
Malnutrition and SarcopeniaICD 9 and ICD 10 codes
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Parenteral NutritionSafe PN practices and Competency ProgramsSustainTM
Product ShortagesAdvanced RD Practice
Focused Physical Assessment SkillSmall bowel feeding tube placementResearch and publishing
Advancing the Science and Practice of Clinical Nutrition and Metabolism for 35 Years
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Malnutrition Awareness and Advocacy
Malnutrition is epidemic in hospitals Disease-related malnutrition ranges between 20%
and 50% of hospitalized patients worldwide Many hospital patients are not even screened for
nutritional status Others are diagnosed as malnourished but are not
provided adequate nutritional therapy.
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Malnutrition Awareness and AdvocacyMalnutrition Decreases
Malnutrition Increases
Immunocompetence Recovery from illness/
injury Mental state Tolerance of treatment Quality of life Prognosis GI, pulmonary, and
renal function
Rate, duration, severity of infections
Overall complication rate
Hard-to-heal wounds, pressure ulcers
Immobility, risk of falling Need of help and careMorbidity Mortality
Malnutrition Leads to Increased Heath Cares Costs
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Nutritional Strategies can Reduce Hospital ReadmissionsReadmissions cost the US Medicare
program about $17 billion each year.
Poor nutrition is a risk factor for readmission.
Canadian Malnutrition Task Force
Oral nutrition supplement research
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ASPEN Taskforce/AND Workgroup
• Which parameters should be used to diagnose malnutrition
• How should malnutrition be documented
• Correlation of current IDNT definitions with existing diagnostic coding terminology
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Figure 1. Etiology-based malnutrition definitions.
White J V et al. JPEN J Parenter Enteral Nutr 2012;36:275-283
Copyright © by The American Society for Parenteral and Enteral Nutrition
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Etiology Based Malnutrition DefinitionsStarvation-related Malnutrition
Chronic starvation without inflammation – anything that limits access to food; for example anorexia nervosa
Chronic Disease-related MalnutritionInflammation is chronic and of mild to moderate
degree – organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity
Acute Disease or Injury-related MalnutritionInflammation is acute and of severe degree –
major infection, burns, trauma or closed head injury
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Proposed Systematic Approach to Assessment
• History and clinical diagnosis• Clinical signs / physical exam• Anthropometric data• Laboratory indicators• Dietary assessment• Functional outcomes
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Current ICD‐9 Terminology forAdult Malnutrition Diagnosis
Coded separately from primary disease/Condition262 – Other Severe Protein‐Calorie Malnutrition263 – Other and Unspecified Protein‐Calorie
Malnutrition260 – Kwashiorkor*261 – Nutritional Marasmus*
* For use in pediatric populations from poorly resourced countries
* 2011 Estimates of hunger in US pediatric populations
* 1 in 5 children (16M)
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Omega 3 Fatty Acids and ARDS
Gone Fishin'The Truth About Omega-3s in Critical Care
NutritionAbbott Nutrition Sponsored Symposium
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ARDSNET EDEN OMEGA TrialNIH Sponsored 2x2x2 Clinical Trial
Bronchodilator vs placeboTrophic vs Full FeedsFish Oil & Antioxidant Supplement vs Placebo
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Fish Oil & Antioxidant Supplement vs Placebo
JAMA. 2011;306(14):1574-1581. doi:10.1001/jama.2011.1435
From: Enteral Omega-3 Fatty Acid, γ-Linolenic Acid, and Antioxidant Supplementation in Acute Lung Injury
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Study Stopped Due to Futility
Placebo group had lower mortality rate- 16.3%
Compared to the Omega 3 group- 26.6%
Also had more Vent and ICU free days.
Normal mortality 25-30% in other ICU studiesPlacebo group was doing better than normOmega 3 group was doing average
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Criticism of Omega Eden
Bolus vs ContinuousUse of different control formula Control group received more calories and
protein Omega 3 group had more diarrhea2 x 2 x 2 design of study
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Consensus of Expert PanelOverwhelming data showing the benefit of
Omega 3 and antioxidant containing formulas
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Consensus of Expert Panel
We should not bolus Omega 3s and Antioxidants
More large multicenter trials of enteral formulas containing EPA/GLA/antioxidants compared to standard feedings are needed
Continued use of products like Oxepa is SAFE
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References White J V et al. JPEN J Parenter Enteral Nutr 2012;36:275-283 Breedveld-Peters JJ, Reijven PL, Wyers CE, et al. Integrated nutritional intervention in the
elderly after hip fracture. A process evaluation. Clin Nutr. 2012; 31:199-205. E Pub 2011 Oct 28.
Gariballa S, Forster S, Walters S, et al. A randomized, double-blind, placebo-controlled trial of nutritional supplementation during acute illness. Am J Med. 2006;119:693-699.
Jensen GL, Mirtallo J, Compher C, et al. Adult starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. JPEN J Parenter Enteral Nutr. 2010;34:156-159.
Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health. 2011;8:514-527
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).McClave SA - JPEN J Parenter Enteral Nutr - 01-MAY-2009; 33(3): 277-316
Martindale R.G., McClave S.A., Vanek V.W., American College of Critical Care Medicine, A.S.P.E.N. Board of Directors , et al: Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: executive summary. Crit Care Med 37. (5): 1757-1761.2009
Rice TW, Wheeler AP, Thompson BT, et al; NHLBI ARDS Clinical Trials Network Enteral omega-3 fatty acid, gamma-linolenic acid, and antioxidant supplementation in acute lung injury. JAMA. 2011;306(14):1574-81.