Lilian Mika Horie

New body fat prediction equations for severely obese patients

BACKGROUND & AIMS Severe obesity imposes physical limitations to body composition assessment. Our aim was to compare body fat (BF) estimations of severely obese patients obtained by bioelectrical impedance (BIA) and air displacement plethysmography (ADP) for development of new equations for BF prediction. METHODS Severely obese subjects (83 female/36 male, mean age=41.6+/-11.6 years) had BF estimated by BIA and ADP. The agreement of the data was evaluated using Bland-Altmans graphic and concordance correlation coefficient (CCC). A multivariate regression analysis was performed to develop and validate new predictive equations. RESULTS BF estimations from BIA (64.8+/-15 kg) and ADP (65.6+/-16.4 kg) did not differ (p>0.05, with good accuracy, precision, and CCC), but the Bland- Altman graphic showed a wide limit of agreement (-10.4; 8.8). The standard BIA equation overestimated BF in women (-1.3 kg) and underestimated BF in men (5.6 kg; p<0.05). Two BF new predictive equations were generated after BIA measurement, which predicted BF with higher accuracy, precision, CCC, and limits of agreement than the standard BIA equation. CONCLUSIONS Standard BIA equations were inadequate for estimating BF in severely obese patients. Equations developed especially for this population provide more accurate BF assessment.

New Specific Equation to Estimate Resting Energy Expenditure in Severely Obese Patients

Calculating the estimated resting energy expenditure (REE) in severely obese patients is useful, but there is controversy concerning the effectiveness of available prediction equations (PE) using body weight (BW). We evaluated the efficacy of REE equations against indirect calorimetry (IC) in severely obese subjects and aimed to develop a new equation based on body composition compartments. One hundred and twenty severely obese patients had their REE measured (MREE) by IC and compared to the most commonly used PE (Harris‐Benedict (HB), Ireton‐Jones, Owen, and Mifflin St. Jeor). In a random sample (n = 60), a new REE equation based on fat‐free mass (FFM) was developed and validated. All PE studied failed to estimate REE in severe obesity (low concordance correlation coefficient (CCC) and limits of agreement of nearly 50% of the sample ±10% of MREE). The HB equation using actual BW exhibited good results for all samples when compared to IC (2,117 ± 518 kcal/day by HB vs. 2,139 ± 423 kcal/day by MREE, P > 0.01); these results were blunted when patients were separated by gender (2,771 vs. 2,586 kcal/day, P < 0.001 in males and 1,825 vs. 1,939 kcal/day, P < 0.001 in females). A new resting energy expenditure equation prediction was developed using FFM, Horie‐Waitzberg, & Gonzalez, expressed as 560.43 + (5.39 × BW) + (14.14 × FFM). The new resting energy expenditure equation prediction, which uses FFM and BW, demonstrates higher accuracy, precision, CCC, and limits of agreement than the standard PE in patients when compared to MREE (2,129 ± 45 kcal/day vs. 2,139 ± 423 kcal/day, respectively, P = 0.1).The new equation developed to estimate REE, which takes into account both FFM and BW, provides better results than currently available equations.

Factors leading to discrepancies between prescription and intake of enteral nutrition therapy in hospitalized patients

OBJECTIVE We investigated factors leading to a reduction in enteral nutrition (EN) prescribed by a nutritional support team (NST) at a general hospital in Brazil. METHODS In this prospective, observational study, hospitalized adults receiving only EN therapy via tube feeding were followed for up to 21 d from July to October 2008. RESULTS The 152 subjects analyzed included 38 (23.5%) ward patients and 124 (76.5%) intensive care unit (ICU) patients. Eighty percent of the targeted feeding volume was achieved on day 4 by 80% of the patients. Reasons for not receiving the total amount of EN prescribed included delay in EN administration (3.1%), abdominal distention (5.6%), patient refusal of treatment (6.8%), feeding tube obstruction (8.6%), vomiting (10.5%), diarrhea (17.9%), unknown causes (17.9%), interference by a non-NST physician (25.9%), accidental feeding tube loss (34%), presence of high gastric residual (34%), and operational logistics at the hospitals Nutrition and Dietetics Service (99.4%). There was a significant association between patients who received <60% of the prescribed EN and external physician interference (P < 0.016). ICU patients also received inadequate EN (P < 0.025). Neurologic patients had a greater chance of receiving >81% of the prescribed EN amount than cardiac patients (odds ratio 3.75, P < 0.01). CONCLUSION Major reasons for inadequate EN intake are (in decreasing order) operational logistical problems, gastric stasis, accidental loss of enteral feeding tube, and interference by an external physician (not an NST member). Cardiologic patients and ICU patients are at a higher risk for inadequacy than neurologic patients.

Constipation is more frequent than diarrhea in patients fed exclusively by enteral nutrition: results of an observational study.

BACKGROUND Digestive complications in enteral nutrition (EN) can negatively affect the nutrition clinical outcome of hospitalized patients. Diarrhea and constipation are intestinal motility disorders associated with pharmacotherapy, hydration, nutrition status, and age. The aim of this study was to analyze the frequency of these intestinal motility disorders in patients receiving EN and assess risk factors associated with diarrhea and constipation in hospitalized patients receiving exclusive EN therapy in a general hospital. MATERIALS AND METHODS The authors performed a sequential and observational study of 110 hospitalized adult patients fed exclusively by EN through a feeding tube. Patients were categorized according to the type of intestinal transit disorder as follows: group D (diarrhea, 3 or more watery evacuations in 24 hours), group C (constipation, less than 1 evacuation during 3 days), and group N (absence of diarrhea or constipation). All prescription drugs were recorded, and patients were analyzed according to the type and amount of medication received. The authors also investigated the presence of fiber in the enteral formula. RESULTS Patients classified in group C represented 70% of the study population; group D comprised 13%, and group N represented 17%. There was an association between group C and orotracheal intubation as the indication for EN (P < .001). Enteral formula without fiber was associated with constipation (logistic regression analysis: P < .001). CONCLUSION Constipation is more frequent than diarrhea in patients fed exclusively by EN. Enteral diet with fiber may protect against medication-associated intestinal motility disorders. The addition of prokinetic drugs seems to be useful in preventing constipation.

Education program on medical nutrition and length of stay of critically ill patients

BACKGROUND & AIMS To evaluate the impact of a multifaceted nutritional educational intervention on the quality of nutritional therapy and clinical outcomes in critically ill patients. METHODS We conducted a prospective, non-blinded study with a non-contemporaneous control group at a 16-bed intensive care unit (ICU) at the Hospital das Clinicas, Department of Gastroenterology, University of Sao Paulo Medical School in Sao Paulo, Brazil. There were three phases. Phase 1: the quality of NT was evaluated in 50 newly admitted intensive care unit patients in a pre-educational program (Pre-EP). Phase 2: nutritional protocols were created and an education program was implemented. Phase 3: another 50 patients were enrolled and observed in a post-educational program (Post-EP) using phase 1 methodology. Nutritional Therapy practice was evaluated through nutritional assessments, adequacy of energy requirements, duration of fasting, and use of early enteral nutrition. Intensive care unit length of stay and hospital length of stay were measured as primary end-points. RESULTS The pre-educational program and post-educational program groups did not differ in age, APACHE II score, gender, or nutritional assessment. The mean ± SD duration of fasting decreased (Pre-EP 3.8 ± 3.1 days vs. Post-EP: 2.2 ± 2.6 days; p = 0.002), the adequacy of nutritional therapy improved (Pre-EP 74.2% ± 33.3% vs. Post-EP 96.2% ± 23.8%; p < 0.001), and enteral nutrition was initiated earlier than 48 h more commonly (Pre-EP 24% vs. Post-E 60%; p = 0.001). Median intensive care unit length of stay decreased (Pre-EP: 18.5 days vs. Post-EP: 9.5 days; p < 0.001) although hospital length of stay did not. CONCLUSION Implementing a multifaceted nutritional educational intervention could improve the quality of nutritional therapy and may decrease intensive care unit length of stay in critically ill patients.

Bioelectrical Impedance Analysis and Skinfold Thickness Sum in Assessing Body Fat Mass of Renal Dialysis Patients

OBJECTIVE In chronic renal failure patients under hemodialysis (HD) treatment, the availability of simple, safe, and effective tools to assess body composition enables evaluation of body composition accurately, in spite of changes in body fluids that occur in dialysis therapy, thus contributing to planning and monitoring of nutritional treatment. We evaluated the performance of bioelectrical impedance analysis (BIA) and the skinfold thickness sum (SKF) to assess fat mass (FM) in chronic renal failure patients before (BHD) and after (AHD) HD, using air displacement plethysmography (ADP) as the standard method. DESIGN This single-center cross-sectional trial involved comparing the FM of 60 HD patients estimated BHD and AHD by BIA (multifrequential; 29 women, 31 men) and by SKF with those estimated by the reference method, ADP. Body fat-free mass (FFM) was also obtained by subtracting the total body fat from the individual total weight. RESULTS Mean estimated FM (kg [%]) observed by ADP BHD was 17.95 ± 0.99 kg (30.11% ± 1.30%), with a 95% confidence interval (CI) of 16.00 to 19.90 (27.56 to 32.66); mean estimated FM observed AHD was 17.92 ± 1.11 kg (30.04% ± 1.40%), with a 95% CI of 15.74 to 20.10 (27.28 to 32.79). Neither study period showed a difference in FM and FFM (for both kg and %) estimates by the SKF method when compared with ADP; however, the BIA underestimated the FM and overestimated the FFM (for both kg and %) when compared with ADP. CONCLUSION The SKF, but not the BIA, method showed results similar to ADP and can be considered adequate for FM evaluation in HD patients.

Obesity, inflammation, vascular reactivity, and cardiocirculatory events

Another point that deserves to be raised is treatment andits impact on the reported aberrations. What are the thera-peutic priorities, and which derangement is more amena-ble to control?Weight loss is not only imperative, it is theoreticallythe best prescription. If excess adipose tissue is elimi-nated, adipokines, including leptin, TNF-alpha, and IL-6, will not be overexpressed; therefore, alleviation of in-

Efeito da suplementação de glutamina sobre variáveis hematológicas e do estado nutricional de ratas desnutridas

RACIONAL: A glutamina e o aminoacido mais abundante no sangue, por desempenhar importante papel no sistema imune. E considerado aminoacido condicionalmente essencial em situacoes como desnutricao proteico-calorica. OBJETIVO: Verificar o efeito da dieta suplementada com glutamina sobre variaveis bioquimicas e hematologicas de ratas submetidas a protocolo de desnutricao, induzido por dieta rica em lactose. METODOS: Ratas Wistar femeas (n=20) e com 21 dias de idade, foram submetidas ou nao a desnutricao calorico-proteica induzida por diarreia, atraves da administracao de dieta rica em lactose 60% durante 15 dias. Apos o periodo de desnutricao, animais eutroficos ou desnutridos permaneceram durante 30 dias com oferta de diferentes dietas (padrao e experimentais). De acordo com estado e tratamento nutricionais, os animais foram distribuidos aleatoriamente em quatro grupos distintos: 1) GC: animais eutroficos + dieta padrao, 2) GD: animais desnutridos + dieta rica em lactose (60%), 3) GDGLN: animais desnutridos + dieta rica em glutamina (2%); e 4) GDP: animais desnutridos + dieta padrao. Apos os 30 dias de tratamento nutricional, amostras de sangue foram obtidas por puncao cardiaca para avaliacao de variaveis bioquimicas (proteinas totais, albumina, ureia) e hematologicas (quantificacao da serie vermelha e branca). RESULTADOS: Apos 15 dias do inicio do experimento o ganho de peso dos grupos GD (46,4 ± 2,60g), GDGLN (39,2 ± 8,9g) e GDP (33,2 ± 11,5g) foi menor em relacao ao controle (64 ± 4,24g, P<0,05). Nos exames bioquimicos observou-se diferenca significativa apenas na dosagem de ureia no GD em relacao aos demais grupos (33,4 ± 4,77 mg/dL, P<0,05). A contagem de leucocitos do GD (3,68 ± 1,0 x103 cel/mm3) mostrou-se diminuida em relacao aos demais grupos (P<0,05) e a serie vermelha nao apresentou diferencas significativas. CONCLUSAO: A desnutricao prejudica o numero de leucocitos sanguineos e esse efeito deleterio e revertido pela simples re-nutricao, independente da suplementacao com glutamina. A ingestao oral de glutamina nao influencia o ganho de peso, variaveis bioquimicas de estado nutricional e numero de leucocitos de animais desnutridos por ingestao de dieta rica em lactose.

A new anthropometric index for body fat estimation in patients with severe obesity

BackgroundBody mass index (BMI) has been used to assess body adiposity, but it cannot adequately reflect body fat (BF) amount. The body adiposity index (BAI) has been shown a better performance than BMI for this purpose, but it can be inaccurate to estimate BF under extreme amounts of fat. Here, we propose a new anthropometric index, the Belarmino–Waitzberg (BeW) index, for specific estimation of BF in severely obese patients.MethodsIn 144 adult patients with severe obesity, BF was estimated by air displacement plethysmography (ADP), as the reference method, along with the follow anthropometric measurements: height, abdominal circumference (AC), hip circumference (HC), weight, BMI (weight/ height2) and BAI ([HC(cm) / height (m)1.5) − 18] × 100). Patients were proportionately distributed into two distinct databases, the building model database (BMD) and the validation model database (VMD), which were applied to develop and validate the BeW index, respectively. The BeW index was tested for gender and ethnicity adjustment as independent variables. The agreement of BF% values obtained by the new index and by BAI with ADP was also assessed.ResultsThe BF% was 52.05 ± 5.42 for ADP and 59.11 ± 5.95 for the BeW index (all results are expressed as the mean ± standard deviation). A positive Pearson correlation (r = 0.74), a good accuracy (Cb = 0.94), and a positive Lin’s concordance correlation (CCC = 0.70) were observed between the two groups. The 95% limits of individual agreement between the BeW index and ADP were 6.8 to 7.9%, compared to − 7.5 to 14.8% between the BAI and ADP. The new index, called the Belarmino–Waitzberg (BeW) index, showed an improvement of 2.1% for the R2 value and a significant gender effect, therefore resulting in two different indexes for females and males, as follows: Female BeW = − 48.8 + 0.087 × AC(cm) + 1.147 × HC(cm) - 0.003 × HC(cm)2 and Male BeW = − 48.8 + 0.087 × AC(cm) + 1.147 × HC(cm) - 0.003 × HC(cm)2–7.195.ConclusionsThe new BeW index showed a good performance for BF estimation in patients with severe obesity and can be superior to the BAI for this purpose.

PP226-MON ASSOCIATION OF ADIPONECTIN LEVELS WITH ENERGY EXPENDITURE, BODY COMPOSITION AND GLUCOSE METABOLISM

PP225-MON SAFETY AND WEIGHT REDUCTION WITH THE ENDOSCOPIC INTRAGASTRIC BALLOON SYSTEM AS PART OF A MULTIMODALITY OBESITY TREATMENT PROGRAM J. Koerner1, I. Wallstabe1, A. Tiedemann1, I. Schiefke1, G. Geigenmuller2, D. Haberzettl3, T. Bley3, A. Weimann3. 1Department for Gastroenterology and Hepatology, 2Department for Cardiology, Angiology and Intensive-Care Medicine, 3Department for General and Visceral Surgery, Klinikum St. Georg, Leipzig, Germany