Many undernourished patients need nutritional support, which aims to increase lean body mass. Oral feeding can be difficult for some patients with anorexia or with eating or absorption problems. Nutritional support is often needed for critically ill patients (1 General reference Many undernourished patients need nutritional support, which aims to increase lean body mass. Oral feeding can be difficult for some patients with anorexia or with eating or absorption problems... read more ).
Behavioral measures that sometimes enhance oral intake include the following:
Encouraging patients to eat
Heating or seasoning foods
Providing favorite or strongly flavored foods
Encouraging patients to eat small portions
Scheduling other care or activities around meals
Assisting patients with feeding
If behavioral measures are ineffective, nutritional support—oral nutrition, enteral tube nutrition Enteral Tube Nutrition Enteral tube nutrition is indicated for patients who have a functioning gastrointestinal (GI) tract but cannot ingest enough nutrients orally because they are unable or unwilling to take oral... read more , or parenteral nutrition Total Parenteral Nutrition (TPN) Parenteral nutrition is by definition given IV. Partial parenteral nutrition supplies only part of daily nutritional requirements, supplementing oral intake. Many hospitalized patients are given... read more —is indicated, except sometimes for dying or severely demented patients Nutritional Support for Dying or Severely Demented Patients Anorexia or loss of appetite is common among dying patients. Measures that may increase oral intake include Using flexible feeding schedules Feeding slowly Giving small portions or favorite... read more .
1. McClave SA, Taylor BE, Martindale RG, et al: 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.). JPEN J Parenter Enteral Nutr 40 (2): 159–211, 2016. doi: 10.1177/0148607115621863.
Predicting Nutritional Requirements
Nutritional requirements are predicted so that interventions can be planned. Requirements can be estimated by formulas or measured by indirect calorimetry. Indirect calorimetry requires use of a metabolic cart (a closed rebreathing system that determines energy expenditure based on total CO2 production), which requires special expertise and is not always available. Thus, total energy expenditure (TEE) and protein requirements usually are estimated.
Total energy expenditure (TEE) varies based on the patient’s weight, activity level, and degree of metabolic stress (metabolic demands); TEE ranges from 30 to 35 kcal/kg/day for people who are sedentary and not under stress to up to 45 kcal/kg/day for people who are critically ill. TEE equals the sum of
Resting metabolic rate (RMR, or resting energy expenditure rate), which is normally about 70% of TEE
Energy dissipated by metabolism of food (10% of TEE)
Energy expended during physical activity (20% of TEE)
Undernutrition can decrease RMR up to 20%. Conditions that increase metabolic stress (eg, critical illness, infection, inflammation, trauma, surgery) can increase RMR but rarely by > 50%.
The Mifflin–St. Jeor equation estimates RMR more precisely and with fewer errors than the commonly used Harris-Benedict equation, usually providing results that are within 20% of those measured by indirect calorimetry. The Mifflin–St. Jeor equation estimates RMR as follows:
TEE can be estimated by adding about 10% (for sedentary people) to about 40% (for people who are critically ill) to RMR.
For healthy people, protein requirements are estimated at 0.8 g/kg/day. However, requirements may be higher (see table ) for the following:
Patients with metabolic stress
Patients with kidney failure requiring dialysis
Patients > 70 years
Assessing Response to Nutritional Support
There is no gold standard to assess response to nutritional support. Clinicians commonly use indicators of lean body mass such as the following:
Body mass index (BMI)
Body composition analysis
Body fat distribution (see Overview of Undernutrition: Physical examination Physical examination Undernutrition is a form of malnutrition. (Malnutrition also includes overnutrition.) Undernutrition can result from inadequate ingestion of nutrients, malabsorption, impaired metabolism, loss... read more and Obesity: Body composition analysis Body composition analysis Obesity is excess body weight, defined as a body mass index (BMI) of ≥ 30 kg/m2. Complications include cardiovascular disorders (particularly in people with excess abdominal fat)... read more )
Nitrogen balance, response to skin antigens, muscle strength measurement, and indirect calorimetry can also be used to assess response to nutritional support.
Nitrogen balance, which reflects the balance between protein needs and supplies, is the difference between amount of nitrogen ingested and amount lost. A positive balance (ie, more ingested than lost) implies adequate intake. Precise measurement is impractical, but estimates help assess response to nutritional support:
Nitrogen intake is estimated from protein intake: nitrogen (g) equals protein (g)/6.25.
Estimated nitrogen losses consist of urinary nitrogen losses (estimated by measuring urea nitrogen content of an accurately obtained 24-hour urine collection) plus stool losses (estimated at 1 g/day if stool is produced; negligible if stool is not produced) plus insensible and other unmeasured losses (estimated at 3 g).
Response to skin antigens, a measure of delayed hypersensitivity, often increases to normal as undernourished patients respond to nutritional support. However, other factors can affect response to skin antigens.
Muscle strength indirectly reflects increases in lean body mass. It can be measured quantitatively, by hand-grip dynamometry, or electrophysiologically (typically by stimulating the ulnar nerve with an electrode).
Levels of acute-phase reactant serum proteins (particularly short-lived proteins such as prealbumin [transthyretin], retinol-binding protein, and transferrin) sometimes correlate with improved nutritional status, but these levels correlate better with inflammatory conditions.
Behavioral measures may avert the need for nutritional support.
Predict the patient's energy requirements based on weight, sex, activity level, and degree of metabolic stress (eg, due to critical illness, trauma, burns, or recent surgery).
Normal protein requirement is 0.8 mg/kg/day, but this amount is adjusted if age is > 70 or if the patient has kidney failure or metabolic stress.
Assess the response to nutritional support by indicators of lean body mass and/or other indicators (eg, nitrogen balance, response to skin antigens, muscle strength measurement, levels of acute-phase reactant serum proteins).