1. Mara Lee Beebe, MS, RD, LD, CNSC Clinical Nutrition Week Highlights January 21-24, 2012 Orlando, Florida Walt Disney World Swan and Dolphin Resort

2. Advancing the Science and Practice of Clinical Nutrition and Metabolism for 35 Years Omega 3 Fatty Acids: History, Metabolism, and Function Immune-modulating Enteral Nutrition Latest Critical Care/ICU Research Epanic Trial – early vs late parenteral nutrition Pep uP Trial – increase protein and energy in take Intercept Trial - EPA and GLA Malnutrition and Sarcopenia ICD 9 and ICD 10 codes

3. Parenteral Nutrition Safe PN practices and Competency Programs Sustain TM Product Shortages Advanced RD Practice Focused Physical Assessment Skill Small bowel feeding tube placement Research and publishing Advancing the Science and Practice of Clinical Nutrition and Metabolism for 35 Years

4. 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.

5. Malnutrition Awareness and Advocacy Malnutrition DecreasesMalnutrition 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 care Morbidity Mortality Malnutrition Leads to Increased Heath Cares Costs

6. Nutritional Strategies can Reduce Hospital Readmissions Readmissions 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

7. 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

8. 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

9. Etiology Based Malnutrition Definitions Starvation-related Malnutrition Chronic starvation without inflammation – anything that limits access to food; for example anorexia nervosa Chronic Disease-related Malnutrition Inflammation is chronic and of mild to moderate degree – organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity Acute Disease or Injury-related Malnutrition Inflammation is acute and of severe degree – major infection, burns, trauma or closed head injury

10. Proposed Systematic Approach to Assessment History and clinical diagnosis Clinical signs / physical exam Anthropometric data Laboratory indicators Dietary assessment Functional outcomes

14. Current ICD ‐ 9 Terminology for Adult Malnutrition Diagnosis Coded separately from primary disease/Condition 262 – Other Severe Protein ‐ Calorie Malnutrition 263 – Other and Unspecified Protein ‐ Calorie Malnutrition 260 – 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)

15. Omega 3 Fatty Acids and ARDS Gone Fishin' The Truth About Omega-3s in Critical Care Nutrition Abbott Nutrition Sponsored Symposium

16. ARDSNET EDEN OMEGA Trial NIH Sponsored 2x2x2 Clinical Trial Bronchodilator vs placebo Trophic vs Full Feeds Fish Oil & Antioxidant Supplement vs Placebo

17. 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

18. 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 studies Placebo group was doing better than norm Omega 3 group was doing average

19. Criticism of Omega Eden Bolus vs Continuous Use of different control formula Control group received more calories and protein Omega 3 group had more diarrhea 2 x 2 x 2 design of study

20. Consensus of Expert Panel Overwhelming data showing the benefit of Omega 3 and antioxidant containing formulas

21. 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

22. 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.