philpan1c

PhilSPEN Online Journal of Parenteral and Enteral Nutrition

(Article | POJ_0116.html) Issue

Original Clinical Investigation

The role of insulin resistance in the outcome of nutritionally high-risk patients managed by a nutrition team

Abstract | Introduction | Methodology | Results | Discussion | Conclusion | References | PDF (756 KB) |Back to Articles Page

Submitted: March 12, 2017 | Posted: March 16, 2018

AUTHORS:

Dr. Yasmin Laura Marie Zuniga and Dr. Luisito O. Llido

INSTITUTION WHERE RESEARCH WAS CONDUCTED:

Clinical Nutrition Service, St. Luke’s Medical Center, Quezon City, Metro-Manila, Philippines

ABSTRACT: | Back

Background: The multidisciplinary nature of critical care management especially in patients with insulin resistance is seen as a major factor in the recovery of the patient; will the role of nutrition be shown when factors like nutrient intake, route of feeding and provision of disease specific nutrition in this group of patients are analyzed?

Objective: a) To determine the effect of insulin resistance (presence of DM type 2 or hyperglycemia) and age in the duration of follow-up days, and b) To determine if the following factors had a role in the positive outcome: adequate calorie and protein intake, route of feeding (role of enteral feeding) and use of disease specific formula and pharmaconutrition.

Methodology: The profile of all patients who were discharged alive from the ICU and hospital were analyzed. These data were collected and analyzed: a) nutritional assessment of “high risk” status, b) age and sex, c) presence or absence of insulin resistance (=diabetes or uncontrolled/poorly controlled blood glucose), d) disease profiles. The primary outcomes are the following: a) duration of follow up days, b) calorie and protein intake (calculated, actual and percent intake), c) route of feeding (oral, enteral, parenteral and mixed), and d) disease specific formula including presence of pharmaconutrition. Statistical tools were T-Test and non-parametric tests for numerical data, regression analysis for categorical and numerical data correlation, p<0.05 was the cut-off for significance.

Results: Of the 68 patients gathered mean age was 59.7 with median of 63 years; male to female ratio was 1.2:1. Insulin resistance was present in 25/68 or 37% of patients; all patients were assessed to be high risk; in the insulin resistance group there were more follow up days (18 days vs. 9 days); more calorie intake (1432 vs. 1402 kcal); and less protein intake (60g/day vs. 66.5 g/day). 68% of patients were on enteral feeding, 52% were disease-specific formulas and 3% to 10% were pharmaconutrition.

Conclusion: Insulin resistance contributes to length of ICU and hospital stay but when managed with a nutrition team which is able to deliver adequate nutrient intake mainly through enteral nutrition with pharmaconutrition and disease specific formulas results to ICU patients discharged alive.

KEYWORDS: Critical care, insulin resistance, nutrition team, disease specific formula, pharmaconutrition, enteral

INTRODUCTION | Back

Nutrition management of nutritionally high risk patients by a nutrition team results to improved outcomes like lowered mortality, but still with increased morbidity. (1,2) The role of diabetes and ageing with concomitant multi-organ failure have played major roles in the outcomes of increased morbidity and duration of hospital stay. (3-6) What has not been fully documented is – when patients were discharged alive - did the presence of insulin resistance, or diabetes, being elderly or the mode of management have an impact on recovery with ultimate reduction of follow-up days? The duration of follow up days may not be a strong measure of management outcome, however, will it consistently show when patients with multiple organ failure recover and are discharged alive? The multidisciplinary nature of the critical care management is the major factor in the recovery of the patient but will the role of nutrition be shown when factors like nutrient intake, route of feeding and provision of disease specific nutrition (7) in this group of patients are analyzed?

In this retrospective study of critically ill  patients who were discharged alive after successful management by a nutrition team, factors that may have contributed to this favorable outcome are analyzed namely: adequate calorie and protein intake, role of enteral feeding and use of disease specific formula and pharmaconutrition. (8) These then are the objectives of the study: a) To determine the effect of insulin resistance (presence of DM type 2 or hyperglycemia) and age in the duration of follow-up days, and b) To determine if the following factors had a role in the positive outcome: adequate calorie and protein intake, route of feeding (role of enteral feeding) and use of disease specific formula and pharmaconutrition.

METHODOLOGY | Back

All patients seen by nutrition team with complete follow-up records as to requirements and nutrition intake and discharged alive were included in this study.  These records are part of the database of the Clinical Nutrition Service, St Luke’s Medical Center, Quezon City, Philippines. These are the data gathered: patient profile data as to: a) nutritional assessment of “high risk” status, b) age and sex, c) presence or absence of insulin resistance (=diabetes or uncontrolled/poorly controlled blood glucose), d) disease profiles. The primary outcomes are the following: a) duration of follow up days, b) calorie and protein intake (calculated, actual and percent intake), c) route of feeding (oral, enteral, parenteral and mixed), and d) disease specific formula including presence of pharmaconutrition

Numerical data are analyzed using T-Tests when normally distributed and non-parametric tests like Wilcoxon or Mann-Whitney U tests when not normally distributed. Means with standard deviation were used together with medians with 95% confidence intervals. Categorical data were analyzed using Chi Square. Linear regression was used to determine correlation between numerical and categorical data, Significance was pegged at p < 0.05. (9,10) The statistical software used was NCSS v. 10. (11)

RESULTS | Back

The study period covered the months from January to September 2011. The total number of patients included in the study was 68. Readmissions were included in the final patient dataset. The total number of patients with insulin resistance or diabetes is 25/68 or 37% of the total patient population. All patients included in the study were admitted to the ICU at one time or another during their confinement in the hospital and were discharged alive.

Patient Profile

Age. The mean age was 59.7 years old with a median of 63 years. Age distribution was skewed to the left meaning there were more elderly patients in the population (95% confidence interval: 62.01 years to 64.9 years old).

Sex. The males total 37 while the females total 31, with a male to female ratio of 1.2 : 1.

Disease profile (Table 1)

The total number of participants' records analyzed was 214. The age and sex distribution of the patients evaluated is shown in Table 1. The male to female ratio is 1.7 to 1.

instbl01

Table 1 shows that patients with insulin resistance had more two (2) to four (4) concomitant organ problems compared to the non-insulin resistant group. In essence they are “more sick” compared to the group with no insulin resistance issues. Yet In spite of all these multi-organ involvements, the patients were able to be discharged alive.

insfig01

Figure 1 shows that patients with insulin resistance issues had more problems in the cardiovascular, cardiac, pulmonary, renal and gastrointestinal systems.

instbl02

The clinical data shows the following: All patients were nutritionally “high risk”. The patients with insulin resistance had longer follow-up days (18 days versus 9 days: longer by 50%).

As to the nutritional intervention, the patients with insulin resistance had significantly more calorie intake, but the percent calorie intake had no difference from the non-insulin resistant group. The calorie and protein intake were all adequate: 92% for the calories and 96.6% for the protein for both groups.

Age and Days of Follow-Up (Figure 2)
As age increases so did the duration of the follow up period – it got longer.

insfig02

Feeding Mode (Table 3)

instbl03

68% of patients were on enteral feeding and only 32 percent had parenteral nutrition. Only 19% of patients were mainly on parenteral nutrition, while the rest were on mixed EN and PN.

Disease specific nutrition (Table 4)

instbl04

There were more disease specific nutrition given to the patients with insulin resistance (52% vs. 20%). This is 37% of all patients given nutrition. Pharmaconutrition was given in 3% to 10% of all patients (these were mostly in parenteral nutrition patients)

DISCUSSION: | Back


All patients were nutritionally “high risk”, were managed by the nutrition team and discharged alive. The presence of insulin resistance led to longer follow up days – meaning there was a slower recovery phase in this group of patients (Table 2 and Figure 2). The systemic and multi-factorial impact of diabetes is seen and documented to have an effect as shown in more diseases in the cardiovascular, cardiac, renal and gastrointestinal system (=effect on the microcirculation) (Figure 1). The presence of more than two or more concomitant organ dysfunctions in the insulin resistance group indicated the more severe nature of the disease in this group, meaning they are “more sick” compared to the other group. (Table 1)

Age is seen to have an impact on longer follow up period. 98% of insulin resistant patients had ages above 60 years old (age range: 63 yrs. to 89 yrs.) Is the duration of recovery affected by old age? This study shows there is a relationship. (Figure 2) How about insulin resistance? This was also significantly related to longer hospital stay (Table 2) These two had a combined effect on the longer duration of response to the management as shown in this study.

What are the factors in the nutrition care process that have contributed to the favorable outcome of these patients in spite of the severity of their health status? The impact of adequate calorie and protein intake is again documented to have played a role with patients achieving more than 90% of their calculated intake requirements (Table 2). A recent report by Yeh DD et al on critically ill surgical patients agrees with this observation. (12) This is the effect of combined oral, enteral and parenteral nutrition which were the goals of the nutrition team management – achieving at least 75% of the calculated requirements. The positive effect of enteral nutrition is also shown in this study where 68% of patients were enterally fed (Table 3). We cannot overemphasize the role of the gut in immune defense and efficient digestion and absorption in this positive outcome. (13)

Disease specific nutrition has a role especially in the insulin resistant patients – more than half of insulin resistant patients received this special form of nutrition, however, the value of pharmaconutrition is not clear due to the small number of patients for analysis. Global literature is also not clear in this area which has resulted to guidelines that do not endorse the use of disease specific nutrition. (7) This study however indicates there is value in providing disease specific nutrition in ICU patients with insulin resistance.

In the overall picture this study has shown the value of having a nutrition team in the management of very sick patients, with or without insulin resistance, especially in the following areas: achieving adequate nutrient intake, use of enteral route, use of disease specific formulas and use of pharmaconutrition.

CONCLUSION: | Back

Insulin resistance contributes to length of ICU and hospital stay but when managed with a nutrition team, which is able to deliver adequate nutrient intake mainly through enteral nutrition with pharmaconutrition and disease specific formulas, results to ICU patients discharged alive.

REFERENCES: | Back

  1. Del Rosario D et al. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients nutritionally assessed as high or low risk. PhilSPEN Online Journal of Parenteral and Enteral Nutrition; Article 9; Issue Jan 2010-2012: 67-74. Available at: http://www.philspenonlinejournal.com/POJ_0006.html. Accessed August 2, 2016.
  2. Manuales G et al. Critical Care Nutrition – the effect of adequate calorie and protein intake on mortality, ventilator days, ICU and hospital stay: report from a private tertiary care hospital in the Philippines. PhilSPEN Online Journal of Parenteral and Enteral Nutrition; Article 13; Feb 2012 - Dec 2014: 8-18. Available at: http://www.philspenonlinejournal.com/POJ_0001.html. Accessed August 3, 2016.
  3. Moore FA, Phillips SM, McClain CJ, Patel JJ, Martindale RG. Nutrition Support for Persistent Inflammation, Immunosuppression, and Catabolism Syndrome. Nutr Clin Pract. 2017 Apr;32(1_suppl):121S-127S.
  4. Van den Berghe G. Beyond diabetes: saving lives with insulin in the ICU. Int J Obes Relat Metab Disord. 2002 Sep;26 Suppl 3:S3-8.
  5. Koch A, Gressner OA, Sanson E, Tacke F, Trautwein C. Serum resistin levels in critically ill patients are associated with inflammation, organ dysfunction and metabolism and may predict survival of non-septic patients.
  6. van Vught LA, Scicluna BP, Hoogendijk AJ Association of diabetes and diabetes treatment with the host response in critically ill sepsis patients. Crit Care. 2016 Aug 6;20(1):252
  7. Taylor BE 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.). Crit Care Med. 2016 Feb;44(2):390-438.
  8. Jones NE, Heyland DK. Pharmaconutrition: a new emerging paradigm. Curr Opin Gastroenterol. 2008 Mar;24(2):215-22.
  9. Dawson B, Trapp R. Basic and Clinical Biostatistics 4th edition; McGraw-Hill 2004: 305-10.
  10. Lang T, Secic M. How to report statistics in medicine 2nd edition; American College of Physicians, Philadelphia 2005: 137-8.
  11. NCSS statistical software. Available at: https://www.ncss.com/software/ncss/
  12. Yeh DD et al. Adequate Nutrition May Get You Home: Effect of Caloric/Protein Deficits on the Discharge Destination of Critically Ill Surgical Patients. JPEN J Parenter Enteral Nutr. 2016 Jan; 40(1): 37-44.
  13. Martindale RG, Warren M. Should enteral nutrition be started in the first week of critical illness? Curr Opin Clin Nutr Metab Care. 2015 Mar;18(2):202-6.
     

Abstract | Introduction | Methodology | Results | Discussion | References | Back to Articles Page