Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: a prospective observational study

Background & aims: The effect of provision of full feeding or permissive underfeeding on mortality in mechanically ventilated critically ill patients in the intensive care unit (ICU) is still controversial. This study investigated the relationship of energy and protein intakes with 60-day mortality, and the extent to which ICU length of stay and nutritional risk status influenced this relationship. Methods: This is a prospective observational study conducted among critically ill patients aged ≥18 years, intubated and mechanically ventilated within 48 h of ICU admission and stayed in the ICU for at least 72 h. Information on baseline characteristics and nutritional risk status (the modified Nutrition Risk in Critically ill [NUTRIC] score) was collected on day 1. Nutritional intake was recorded daily until death, discharge, or until the twelfth evaluable days. Mortality status was assessed on day 60 based on the patient's hospital record. Patients were divided into 3 groups a) received <2/3 of prescribed energy and protein (both <2/3), b) received ≥2/3 of prescribed energy and protein (both ≥2/3) and c) either energy or protein received were ≥2/3 of prescribed (either ≥2/3). The relationship between the three groups with 60-day mortality was examined by using logistic regression with adjustment for potential confounders. Sensitivity analysis was performed to examine the influence of ICU length of stay (≥7 days) and nutritional risk status. Results: Data were collected from 154 mechanically ventilated patients (age, 51.3 ± 15.7 years; body mass index, 26.5 ± 6.7 kg/m2; 54% male). The mean modified NUTRIC score was 5.7 ± 1.9, with 56% of the patients at high nutritional risk. The patients received 64.5 ± 21.6% of the amount of energy and 56.4 ± 20.6% of the amount of protein prescribed. Provision of energy and protein at ≥2/3 compared with <2/3 of the prescribed amounts was associated with a trend towards increased 60-day mortality (Adjusted odds ratio [Adj OR] 2.23; 95% confidence interval [CI], 0.92-5.38; p = 0.074). No difference in mortality status was found between energy and protein provision at either ≥2/3 compared with <2/3 of the prescribed amounts (Adj OR 1.61, 95% CI, 0.58-4.45; p = 0.357). Nutritional risk status, not ICU length of stay, influenced the relationship between nutritional adequacy and 60-day mortality. Conclusions: Energy and protein adequacy of ≥2/3 of the prescribed amounts were associated with a trend towards increased 60-day mortality among mechanically ventilated critically ill patients. However, neither energy nor protein adequacy alone at ≥ or <2/3 adequacy affect 60-day mortality. Increased mortality was associated with provision of energy and protein at ≥2/3 of the prescribed amounts, which only affected patients with low nutritional risk

Prevalence and duration of reasons for enteral nutrition feeding interruption in a tertiary intensive care unit

Objectives: Intensive care unit (ICU) enteral nutrition (EN) can involve frequent feeding interruption (FI). The prevalence, causes, and duration of such interruption were investigated. Methods: Reasons for EN FI identified from extensive literature review were prospectively collected in adult mechanically ventilated critically ill patients. Results were reported by descriptive statistics. Baseline and nutritional characteristics between patients who died and those alive at day 60 were compared. Results: A total of 148 patients receiving ≥1 day of EN for the full 12-day observational period were included in the analysis. About 332 episodes of EN FI were recorded and contributed to 12.8% (4190 hours) of the total 1367 evaluable nutrition days. For each patient, FI occurred for a median of 3 days and the total duration of FI for the entire ICU stay was 24.5 hours. Median energy and protein deficits per patient due to FI for the entire ICU stay were -1780.23 kcal and -100.58 g, respectively. Duration of FI, days with FI, and the amount of energy and protein deficits due to FI were not different between patients who had died and those who were still alive at day 60 (all P > 0.05). About 72% of the total duration of EN FI was due to procedural-related and potentially avoidable causes (primarily human factors), while only about 20% was due to feeding intolerances. Conclusions: EN FI occurred primarily due to human factors, which may be minimized by adherence to an evidence-based feeding protocol as determined by a nutrition support team

Determinants of metabolic syndrome among Malaysian government employees

Introduction: The metabolic syndrome comprises a collection of cardiovascular disease risks, which has been demonstrated to predict type 2 diabetes mellitus and cardiovascular disease. Metabolic syndrome is a crucial health concern in Malaysia, with a prevalence of about 42.5% in the general population based on the ‘Harmonized’ definition. The aim of this study was to ascertain the association between socioeconomic status among Malaysian government employees with metabolic syndrome, compared with those without metabolic syndrome. Furthermore, this study also aimed to ascertain the associated obesity indicators for metabolic syndrome among employees—explicitly body mass index, waist circumference, waist-to-hip ratio, body fat percentage, fat mass index, and waist-to-height ratio. Methods: This cross-sectional study was undertaken at government agencies in Putrajaya, Malaysia, via multi-stage random sampling. A total of 675 government employees were randomly sampled from a list of 3,173 government employees working in five government agencies under five geographical areas. Data on socioeconomic status, anthropometric, biochemical, and clinical assessments were collected. Results: Employees who were males had higher metabolic syndrome prevalence compared to their counterparts (p=0.019). In addition, employees aged between 20 to younger than 30 years had lowest metabolic syndrome prevalence (p=0.002). The risk of having metabolic syndrome was almost 10 times more likely in men with a waist-to-hip ratio of ≥0.90 compared to men with a waist-to-hip ratio of <0.90 (p<0.001). Women with a waist-to-hip ratio of ≥0.85 were approximately 33 times more likely to have metabolic syndrome as compared to women with waist-to-hip ratios of <0.85 (p<0.001). Men with a waist circumference of ≥90 cm were approximately twice as likely to have metabolic syndrome, compared to men with waist circumferences of <90 cm (p=0.030). The risk of having metabolic syndrome was almost three times more likely in women with a waist circumference of ≥80 cm compared to women with waist circumferences of <80 cm (p<0.001). Furthermore, the risk of having metabolic syndrome was almost five times more likely in women with fat mass indexes in Quartile 4 (≥7.93), compared to women with fat mass indexes in Quartile 1 (<5.25) [p<0.001]. On the other hand, men with waist-to-height ratios of <0.445 were 75% less likely to have metabolic syndrome as compared to men with waist-to-height ratios of ≥0.625 (p=0.020). Women with waist-to-height ratios of 0.445 to <0.525 were 95% less likely to have metabolic syndrome as compared to women with waist-to-height ratios of ≥0.625 (p<0.001). In addition, women with waist-to-height ratios of 0.525 to <0.625 were 77% less likely to have metabolic syndrome as compared to women with waist-to-height ratios of ≥0.625 (p<0.001). Conclusion: Gender and age were associated with metabolic syndrome prevalence. Waist-to-hip ratio, waist circumference, and waist-to-height ratio seems to be the better obesity indicators to predict the presence of metabolic syndrome than body mass index and body fat percentage in both men and women

Glycemic index of selected watermelon (Citrullus lanatus)

The glycemic index (GI) was conducted on 14 healthy subjects who have consumed 25 g of available carbohydrate portions of glucose (standard food) and four test foods (red-fleshed seedless watermelon, red-fleshed seeded watermelon and yellow-fleshed watermelon, as well as a glass of red-fleshed seedless watermelon juice) in random order after an overnight fast. Red-fleshed seedless watermelon was usually processed as juice than red-fleshed seeded and yellow-fleshed watermelon. Blood glucose was measured at 0, 15, 30, 45, 60, 90 and 120 mins after intake of the foods. Incremental areas under the curve were calculated, whereas the glycemic index was determined by expressing the area under the curve after the test foods, as a percentage of the mean area under the curve after consuming standard food, was carried out. The results showed that the area under the curve for a portion of red-fleshed seedless was 98.17±6.39, red-fleshed seeded (94.10±7.45), yellow-fleshed (92.95±8.73), and a juice of redfleshed seedless (98.89±6.38) did not have any significant difference (p < 0.05). The GI of a portion fruit and the juice of red-fleshed seedless watermelon were 51, while red-fleshed seeded watermelon was 48 and yellow-fleshed watermelon was 47. The study showed red-fleshed watermelon and yellow-fleshed watermelon could be classified as low GI food (GI value below 51) with strong influenced by the fructose content and no significant difference from GI value among red and yellow watermelons. This research will help the experts to explore more based of GI value and also be used as a database reference

Nutritional status, glycemic control and its associated risk factors among a sample of type 2 diabetic individuals, a pilot study

Background: The prevalence of type 2 diabetes is increasing in Malaysia, with most patients poorly controlled. Hence, this study aimed to determine nutritional and metabolic status as well as blood pressure of Malaysian patients with type 2 diabetes mellitus and identify associated risk factors for poor glycemic control. Materials and Methods: A total of 104 type 2 diabetic patients were recruited and completed a questionnaire covering socio-demographic status, 3-day diet records, and physical activity. Anthropometry and glycemic control parameters, lipid profile and blood pressure were also measured. Results: Subjects were on average 56.7±9.9 years old with a mean duration of diabetes of 6.5 ± 5.0 years. The mean hemoglobin A1c of the subjects was 7.6% ± 1.4%, with only 20.2% achieving the target goal of <6.5% with no significant differences between genders. The mean body mass index was 26.9 ± 4.7 kg/m2, with 86.5% either were overweight or obese. Only 10.6% of the subjects exercised daily. The proportions of macronutrients relative to total energy intake were consistent with the recommendations of most diabetes associations. The adjusted odds of having poor glycemic control were 3.235 (1.043-10.397) (P < 0.05) higher among those who had high density lipoprotein cholesterol levels below the normal range. Those taking one or two types of oral anti-diabetic drugs had 19.9 (2.959-87.391) (P < 0.01) and 14.3 (2.647-77.500) (P < 0.01) higher odds of poor glycemic control respectively compared to those who were being treated by diet alone. Conclusion: Poor glycemic control was prevalent among Malaysian diabetic patients, and this could be associated with low levels of HDL and being treated with oral anti-diabetes agents

Obesity-related behaviors of Malaysian adolescents: a sample from Kajang district of Selangor state

This study aims to determine the association between obesity-related behaviors (dietary practices, physical activity and body image) and body weight status among adolescents. A total of 382 adolescents (187 males and 195 females) aged 13 to 15 years in Kajang, Selangor participated in this study. Majority of the respondents were Malays (56.0%), followed by Chinese (30.1%) and Indians (13.9%). Dietary practices, physical activity and body image of the adolescents were assessed through the eating behaviors questionnaire, two-day dietary record, two-day physical activity record and multi-dimensional body image scale (MBIS), respectively. Body weight and height were measured by trained researchers. The prevalence of overweight and obesity (19.5%) was about twice the prevalence of underweight (10.5%). About two-thirds of the respondents (72.3%) skipped at least one meal and half of them (56.2%) snacked between meals with a mean energy intake of 1,641 ± 452 kcal/day. More than half of the respondents (56.8%) were practicing sedentary lifestyle with a mean energy expenditure of 1,631 ± 573 kcal per day. Energy intake (r = 0.153, P < 0.05), physical activity (r = 0.463, P < 0.01) and body image (r = 0.424, P < 0.01) were correlated with BMI. However, meal skipping, snacking and energy expenditure per kg body weight were not associated with body weight status. Multiple linear regression analysis showed that body image, physical activity and energy intake contributed significantly in explaining body weight status of the adolescents. In short, overweight and obesity were likely to be associated not only with energy intake and physical activity, but also body image. Hence, promoting healthy eating, active lifestyle and positive body image should be incorporated in future obesity prevention programmes in adolescents

Feeding adequacy among critically ill patients in the Intensive Care Unit and its association with clinical outcomes: a narrative review

The Intensive Care Unit (ICU) is one of the disciplines in the hospital that provides close monitoring to the seriously ill or injured patients, also known as the critically ill patients. Critically ill patients in the ICU are usually unable to maintain volitional oral nutrition intake and therefore require nutritional therapy. Nutritional therapy can be delivered via the enteral or parenteral route. Optimal nutrition adequacy (i.e. neither underfeeding nor overfeeding) is very important for better clinical outcome. However, the problem of suboptimal feeding adequacy continues to be reported over the years. This article attempts to give an overview of the literature on feeding adequacy and the relationship of feeding adequacy with clinical outcomes among the critically ill patients in the ICU