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Review
, 21 (Suppl 3), 316

Tailoring Nutrition Therapy to Illness and Recovery

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Review

Tailoring Nutrition Therapy to Illness and Recovery

Paul E Wischmeyer. Crit Care.

Abstract

Without doubt, in medicine as in life, one size does not fit all. We do not administer the same drug or dose to every patient at all times, so why then would we live under the illusion that we should give the same nutrition at all times in the continuum of critical illness? We have long lived under the assumption that critical illness and trauma lead to a consistent early increase in metabolic/caloric need, the so-called "hypermetabolism" of critical illness. What if this is incorrect? Recent data indicate that early underfeeding of calories (trophic feeding) may have benefits and may require consideration in well-nourished patients. However, we must confront the reality that currently ICU nutrition delivery worldwide is actually leading to "starvation" of our patients and is likely a major contributor to poor long-term quality of life outcomes. To begin to ascertain the actual calorie and protein delivery required for optimal ICU recovery, an understanding of "starvation" and recovery from starvation and lean body mass (LBM) loss is needed. To begin to answer this question, we must look to the landmark Minnesota Starvation Study from 1945. This trial defines much of the world's knowledge about starvation, and most importantly what is required for recovery from starvation and massive LBM loss as occurs in the ICU. Recent and historic data indicate that critical illness is characterized by early massive catabolism, LBM loss, and escalating hypermetabolism that can persist for months or years. Early enteral nutrition during the acute phase should attempt to correct micronutrient/vitamin deficiencies, deliver adequate protein, and moderate nonprotein calories in well-nourished patients, as in the acute phase they are capable of generating significant endogenous energy. Post resuscitation, increasing protein (1.5-2.0 g/kg/day) and calories are needed to attenuate LBM loss and promote recovery. Malnutrition screening is essential and parenteral nutrition can be safely added following resuscitation when enteral nutrition is failing based on pre-illness malnutrition and LBM status. Following the ICU stay, significant protein/calorie delivery for months or years is required to facilitate functional and LBM recovery, with high-protein oral supplements being essential to achieve adequate nutrition.

Keywords: Calories; Critical care; ICU; Lean body mass; Malnutrition; Muscle; Protein; Quality of life; Recovery.

Conflict of interest statement

Ethics approval and consent to participate

This is a review and concept manuscript. No human subjects were enrolled or human data collected for this manuscript.

Consent for publication

Only individual descriptions from the author PEW is contained in these data, who gave permission to publish all included information.

Competing interests

PWW is associate editor of Clinical Nutrition (Elsevier). PEW has received grant funding from Canadian Institutes of Health Research, Baxter, Fresenius, Lyric Pharmaceuticals, Isomark Inc., and Medtronics. PEW has served as a consultant on Improving Nutrition Care in ICU and Perioperative Medicine to Nestle, Abbott, Fresenius, Baxter, Medtronics, Nutricia, and Lyric Pharmaceuticals, and to Takeda for research related to this work. PEW has received honoraria or travel expenses for lectures on improving nutrition care in illness from Abbott, Fresenius, and Medtronics.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Minnesota Starvation Study recruitment brochure from May 27, 1944. Adapted from [6]
Fig. 2
Fig. 2
Photograph from Life magazine on July 30, 1945 (volume 19, number 5, p. 43) showing men enrolled in the Minnesota Starvation Study during the semi-starvation diet. Adapted from [6]
Fig. 3
Fig. 3
Substrate mobilization in catabolic response to stress and injury during acute phase. In well-nourished patients, the body is capable of generating 50–75% of glucose needs in the first few days of ICU stay. Patients still require adequate protein delivery (> 1.0 g/kg/day) due to muscle catabolism, but may benefit from reduced nonprotein kilocalorie delivery (~ 15 kcal/kg/day). Adapted from [9]
Fig. 4
Fig. 4
Proposal for targeted nutrition delivery across phases of critical illness. Adapted from [18]
Fig. 5
Fig. 5
Targeted nutritional and metabolic therapy in critical illness. Adapted from [18]

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