Australian Critical Care 34 (2021) 3e8

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Australian Critical Care

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Research paper

Nutrition management of obese critically ill adults: A survey of critical

care dietitians in Australia and New Zealand
Kate J. Lambell, BHSc, MNutrDiet a, b, *
Eliza G. Miller, BFoodSc&Nutr(Hons), PhD a
Oana A. Tatucu-Babet, BNutDiet(Hons), PhD a
Sandra Peake, MBBS, PhD a, c
Emma J. Ridley, BNutDiet, MPH, PhD a, b
a
Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, VIC, Australia
b
Nutrition Department, The Alfred Hospital, Melbourne, VIC, Australia
c
Department of Intensive Care, The Queen Elizabeth Hospital, Woodville South, SA, Australia

article information a b s t r a c t

Article history: Background: Guideline recommendations for nutrition therapy in critically ill obese adults are incon-
Received 2 April 2020 sistent. This study aimed to describe how dietitians working in an intensive care unit (ICU) in Australia
Received in revised form and New Zealand (ANZ) approach managing the nutritional needs of an obese, critically ill adult.
19 June 2020
Methods: Invitations to participate were via personal email communication. The survey was also
Accepted 27 June 2020
disseminated through a research email list and a dietitian-based newsletter. The multiple-choice case-
based survey consisted of 12 questions relating to nutrition prescription and were based on international
Keywords:
nutrition guideline recommendations including (i) weight used in energy and protein predictive
Critical care
Nutrition
equations; (ii) energy and protein prescription at ICU admission and day 7, (iii) commencement of enteral
Obesity nutrition, and; (iv) use of supplemental protein. Data are reported as n (%).
Survey Results: Sixty-three dietitians participated in the survey. Most commonly, adjusted body weight calcu-
lated as ‘weight at BMI 25 kg/m2 þ 25% excess weight’ was used in equations to guide energy (44 re-
spondents, 70%) and protein (39 respondents, 62%) prescription. At day 1, energy and protein
prescription was most commonly based on the European Society of Parenteral and Enteral Nutrition
(ESPEN) guideline recommendation of 20e25 kcal/kg (39 respondents, 62%) and 1.3 g protein/kg
adjusted body weight (36 respondents, 57%). Thirteen (21%) respondents had an indirect calorimetry
device in their ICU to measure energy expenditure. On day 7, the ESPEN recommendations were again
the most common method used for prescribing energy (30 respondents, 48%) and protein (23 re-
spondents. 48%) needs. Thirty-eight dietitians (60%) reported they would use early supplemental protein
to meet protein requirements.
Conclusions: ICU dietitians in ANZ who responded to the survey most commonly report using the ESPEN
ICU guideline recommendations (20e25 kcal/kg and 1.3 g protein/kg adjusted body weight) to guide
nutrition prescription in an obese critically ill adult. Prospective studies are required to confirm these
findings.
© 2020 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

* Corresponding author. Australian and New Zealand Intensive Care Society
Research Centre, School of Public Health and Preventative Medicine, Monash Uni-
versity, Level 3, 555 St Kilda Road, Melbourne, VIC, 3004, Australia.
E-mail addresses: kate.lambell@monash.edu (K.J. Lambell), eliza.miller@
monash.edu (E.G. Miller), oana.tatucu@monash.edu (O.A. Tatucu-Babet), Sandra.
peake@sa.gov.au (S. Peake), emma.ridley@monash.edu (E.J. Ridley).
Obesity is defined as a body mass index (BMI) of 30 kg/m2, and
is increasing in the population with one in three (31%) Australians
reported as obese in 2017e2018, compared with one in five (19%) in
1995.1 This trend has also been reported in patients admitted to
intensive care units (ICUs), with the prevalence of obesity reported

https://doi.org/10.1016/j.aucc.2020.06.005
1036-7314/© 2020 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.
4 K.J. Lambell et al. / Australian Critical Care 34 (2021) 3e8
to be 20%.2 Obesity in critical illness has been associated with an
increased risk of respiratory and cardiovascular complications, in-
sulin resistance, loss of lean muscle mass, and wide variations in
macronutrient metabolism, all of which complicate nutritional
management.2,3 Moreover, clinical guidelines informing nutrition
practice for the critically ill obese patient are largely based on
expert consensus, with minimal robust evidence.4,5
The most common international clinical guidelines for the
nutritional management of critically ill patients (Society of Critical
Care Medicine/American Society for Parenteral and Enteral
Nutrition [SCCM/ASPEN] and European Society for Parenteral and
Enteral Nutrition [ESPEN]) provide specific recommendations
regarding energy and protein prescription and delivery in obese
critically ill adults.4,5 Both guidelines recommend that indirect
calorimetry (IC) should be used to measure energy expenditure.
However, energy targets are conflicting. Specifically, the SCCM/
ASPEN guidelines recommend hypocaloric feeding (calorie de-
livery less than calorie needs) according to measured or estimated
requirements and BMI category.4 Conversely, the ESPEN guidelines
support isocaloric feeding (calorie delivery equal to calorie needs)
after ICU day 3.5 Protein targets also differ, thus making the
bedside application of the guidelines confusing for clinicians.
In preparation for a program of research investigating nutri-
tion therapy in obese critically ill adults, we aimed to describe
how Australian and New Zealand (ANZ) ICU dietitians report
managing the nutrition needs of an obese patient admitted to
their ICU.
2. Methods
2.1. Survey
We designed an anonymous, scenario-based, self-administered
questionnaire using an online website (Google Forms®). The survey
asked about the nutrition management of an obese (BMI 38 kg/m2),
critically ill, ventilated patient admitted to the ICU with respiratory
distress and who remained critically ill with multiorgan failure on
day 7. We asked 12 questions relating to energy and protein pre-
scription based on international clinical guideline recommenda-
tions (Table 1) including the following:
1. What weight would be used in equations for determining en-
ergy and protein prescription?
2. What equation would be used to guide energy and protein
prescription on ICU admission (day 1) and ICU day 7?
3. When and how quickly would enteral nutrition be commenced?
and;
Table 1
Clinical guideline recommendations for energy and protein prescription in non-obese and obese critically ill adults.
Recommendation BMI Category ESPEN, 20185
Energy Non-obese  Use IC to measure energy expenditure
(BMI <30 kg/m2)  ICU day 1e3: target <70% measured energy expenditure, after ICU
day 3: aim to meet 80e100% measured energy expenditure
 If no IC, 20e25 kcal/kg actual body weight/day
Obese  Same as for non-obese, but use adjusted body weight in
(BMI 30 kg/m2) predictive equation
Protein Non-obese  1.3 g/kg/day delivered progressively
(BMI <30 kg/m2)
Obese  Same as for non-obese but use adjusted body weight in
(BMI 30 kg/m2) predictive equation
BMI, body mass index; ESPEN, European Society for Parenteral and Enteral Nutrition; IC, indirect calorimetry; SCCM/ASPEN, Society of Critical Care Medicine/American Society
for Parenteral and Enteral Nutrition.
4. Would supplemental protein, in addition to standard enteral
formula, be prescribed if a 30g/day protein deficit existed on ICU
day 7?
The detailed clinical scenario and survey questions are displayed
in Supplementary Appendix 1. Respondents were asked to report
what would usually happen at the bedside in their ICU (not what
the ideal scenario would be) and were required to answer all
questions. Before finalisation of the questions, the survey was
piloted on five critical care dietitians for flow and clarity. Free-text
answers were minimised to reduce any possible errors in inter-
pretation. The study was approved by the Monash University Hu-
man Research Ethics Committee (Project ID 16956), and a waiver of
consent granted.
2.2. Target population and survey distribution
Dietitians working in an ICU in ANZ were contacted using
investigator contacts maintained at the ANZ Intensive Care
Research Centre and via the ANZ Intensive Care Society Clinical
Trials Group mailing list. Each dietitian was invited by email to
respond to the online questionnaire on the 21st February 2019,
with a follow-up reminder email sent on the 18th March 2019.
Dietitians were also invited to participate via an online dietitian-
based newsletter (Dietitian Connection), which included a link to
the survey. All responses were recorded during a 5-week period
from 01/03/2019 to 05/04/2019. Although consent was not required
and participation was voluntary, it was assumed completion of the
survey indicated consent from the respondent. Participants were
able to view the survey in advance, allowing them time to assess if
they were happy with the content before participating.
2.3. Data management
Responses were downloaded from Google Forms® directly into
an Excel spreadsheet (XLS, Microsoft Excel®). No imputation was
undertaken for missing data. Where open-text answers were pro-
vided, data were categorised by investigators (K.J.L. and E.G.M.) into
groups with similar responses. Responses are shown as number (%)
for each given question.
3. Results
3.1. Respondents
There were 63 respondents. As the survey was disseminated by
email and newsletter lists, it was not possible to calculate a
SCCM/ASPEN, 20164
 Use IC to measure energy expenditure
 If no IC, 25e30 kcal/kg actual body weight/day
 If IC is used, target 65e70% measured energy
expenditure
 If no IC, BMI 30e50 kg/m2 ¼ 11e14 kcal/kg actual
body weight/day; BMI >50 kg/m2 ¼ 22e25 kcal/kg
ideal body weight/day
 1.2e2 g/kg/day
 BMI 30e40 kg/m2 ¼ 2 g/kg ideal body weight/day
 BMI  40 ¼ up to 2.5 g/kg ideal body weight/day
 K.J. Lambell et al. / Australian Critical Care 34 (2021) 3e8 5

Table 2
Survey responses for weight used in equations to guide energy and protein prescription on initial assessment and at ICU day 7.

Weight used in equations Initial assessment ICU day 7

Energy Protein Energy Protein

n (%) n (%) n (%) n (%)

Adjusted body weighta ¼ [weight at BMI of 25 kg/m2] þ 25% excess weightb 44 (70) 39 (62) 45 (71) 41 (65)
Actual weight 6 (10) 8 (13) 6 (10) 7 (11)
Ideal body weight ¼ [weight at BMI of 25 kg/m2] 5 (8) 7 (11) 5 (8) 7 (11)
Adjusted body weighta ¼ [0.9  height in cme100 (male)] þ20e25% excess weightb 4 (6) 5 (8) 3 (5) 5 (8)
Other 4 (6) 4 (6) 4 (6) 3 (5)
Total 63 (100) 63 (100) 63 (100) 63 (100)

BMI, body mass index; ICU, intensive care unit.

a
as per recommendations outlined in the 2019 European Society for Parenteral and Enteral Nutrition ICU guidelines.
b
excess weight ¼ actual body weight e ideal body weight (weight at BMI 25 kg/m2).

response rate. Furthermore, the survey was anonymous and no
further information on respondents was collected.
3.2. Energy and protein prescription
3.2.1. Initial assessment
The most commonly reported weight used in equations to
determine energy and protein prescription was adjusted body
weight calculated as ‘weight at BMI 25 kg/m2 þ 25% excess weight’
(44 respondents, 70% for energy and 39, 62% for protein), Table 2.
Thirty-one (49%) respondents stated they would weigh the patient
at the initial assessment.
Thirteen (21%) respondents reported they had an IC device in
their ICU to measure energy expenditure. Where IC was available at
initial assessment, five of the 13 (38%) respondents said they would
target energy delivery at 100% measured energy expenditure,
whereas five (38%) said they would target 65e75%, and one said
they would target 80% measured energy expenditure. The
remaining two respondents reported that IC would only be used
after ICU day 5 and they would target 100% measured expenditure
at this time. If an equation was used to guide energy prescription,
most commonly, the ESPEN recommendation of 20e25 kcal/kg
adjusted body weight was used (39 respondents, 62%). The SCCM/
ASPEN guideline recommendation of 11e14 kcal/kg actual body
weight was the least common guideline-based method used for
energy prescription (5 respondents, 8%) (Fig. 1). Overall, the most
common method used to determine protein prescription was the
ESPEN guideline recommendation of 1.3 g protein/kg adjusted body
weight (36 respondents, 57%) (Fig. 2).
3.2.2. ICU day 7
Similar to day 1, most respondents (45, 71%) reported using
adjusted body weight (‘weight at BMI 25 kg/m2 þ 25% excess
weight’) in predictive equations on day 7 (Table 2). The ESPEN
recommendation of 20e25 kcal/kg adjusted body weight remained
the most frequently reported method for energy prescription (30
respondents, 48%) (Fig. 1). The ASPEN recommendation was
again the least common guideline-based method used (five re-
spondents, 8%); however, 20 respondents (32%) chose ‘other’,
indicating they would use a noneguideline-based recommenda-
tion to guide energy prescription (e.g. calculate energy re-
quirements using two different guideline recommendations and
use the midpoint value).
On day 7, 23 (37%) respondents reported prescribing 1.3 g
protein/kg adjusted body weight (ESPEN recommendation), Fig. 2
nine (14%) chose the SCCM/ASPEN ICU guideline recommendation
of 2 g/kg ideal body weight. A further 23 (37%) chose ‘other’,
indicating they would use a noneguideline-based method to
guide protein prescription (e.g. calculate protein requirements
using two different guideline recommendations and use the
midpoint value). When presented with a 30g/day protein deficit
according to protein prescriptions, most respondents (38, 60%)
indicated they would provide additional protein, mostly via an
enteral modular supplement (37 respondents, 57%). When asked
on which day supplemental protein should commence, 33 re-
spondents provided an answer, with 21 (64%) stating they would
commence on ICU day 0e5, followed by ICU day 5e10 (7 re-
spondents, 21%). The remaining five (15%) respondents said sup-
plementation would depend on multiple factors and they were
unable to state a specific start date.

Fig. 1. Method used to guide energy prescription at initial assessment and at ICU day 7. ESPEN, European Society for Parenteral and Enteral Nutrition; ICU, intensive care unit; SCCM/
ASPEN, Society of Critical Care Medicine/American Society of Parenteral and Enteral Nutrition.
6 K.J. Lambell et al. / Australian Critical Care 34 (2021) 3e8
Fig. 2. Method used to guide protein prescription at initial assessment and at ICU day 7. ESPEN, European Society for Parenteral and Enteral Nutrition; ICU, intensive care unit;
SCCM/ASPEN, Society of Critical Care Medicine/American Society of Parenteral and Enteral Nutrition.
3.3. Commencement of enteral nutrition
Respondents most commonly reported commencing enteral
nutrition at a low rate with a slow progression to an hourly goal (49,
77%). Less common responses were starting enteral nutrition at the
target hourly rate (12, 19%), keeping enteral nutrition at a low rate
(1, 2%), and ‘other’ (1, 2%).
4. Discussion
To our knowledge, this is the first study to describe how ICU
dietitians working in ANZ report how they would manage the
nutrition needs of an obese, critically ill adult. Although the
measurement of energy expenditure over predictive equations to
guide energy delivery is recommended in both the SCCM/ASPEN
and ESPEN ICU nutrition clinical guidelines, the minority of re-
spondents had access to IC in their ICU. Practice was variable for
how energy and protein prescriptions were determined, with the
ESPEN guideline recommendations being the most widely used.
On ICU day 7, there was greater variation in responses, with
approximately one third of respondents reporting they would use
a noneguideline-based method to guide energy and protein
prescriptions.
It is well described in general critically ill populations that en-
ergy estimates are imprecise when compared with measured en-
ergy expenditure.6 Inaccuracies are known to be more pronounced
in obese individuals, which may be a result of the original equations
having limited representation from obese individuals and/or the
wide variations in metabolically active tissue, which are difficult to
assess by BMI alone.7e9 It is because of these challenges that both
the SCCM/ASPEN and ESPEN guidelines recommend the use of IC to
guide energy delivery.4,5 Despite this, the results from our study
highlight that in ANZ, this recommendation has not been translated
into practice. Major issues influencing uptake of guideline recom-
mendations into clinical practice include complexity, trialability,
and observability.10 While the present study did not explore rea-
sons behind this, it could be hypothesised in the case of IC that the
cost, reproducibility of results, and lack of expertise in the appli-
cation of the equipment are likely contributors. Regardless of
whether measured or estimated energy expenditure is used, there
have been no reported benefits on clinical and/or functional out-
comes when IC is used to guide nutrition therapy over simple
equations in general ICU patients.11e14 There is an urgent need to
understand if guiding energy delivery by measured needs, versus a
simple predictive equation, improves outcomes, particularly in
high-risk populations, such as the obese.
The heterogeneity in methods used to calculate nutritional
requirements most likely reflects the conflicting and limited
supporting evidence for the current guideline recommendations.
The SCCM/ASPEN guideline recommendations4 are based on
expert consensus and two randomised controlled trials con-
ducted over 20 years ago.15,16 Both trials were small (n ¼ 30 and
n ¼ 16) and aimed to investigate whether hypocaloric, high
protein feeding delivered to critically ill patients via parenteral
nutrition could achieve nitrogen balance similar to those
receiving standard care.15,16 Nitrogen balance was found to be
comparable between treatment groups, but both trials were
underpowered to detect differences in patient-centred outcomes.
Recently, a large enteral feeding, randomised, double-blind trial
(n ¼ 3957) investigated the impact of augmented energy delivery
using an energy-dense enteral nutrition formulation versus usual
care in critically ill patients on 90-day mortality and functional
outcomes at 6 months.17,18 Energy-dense enteral nutrition
resulted in a mean total energy intake of 30 kcal/kg ideal body
weight/day compared with an isocaloric formulation (22 kcal/kg
ideal body weight/day). Importantly both groups received the
same amount of protein (~1.1 g/protein/kg ideal body weight/
day).17 Although the treatment effect for the primary outcome
(90-day mortality) was not statistically significant, the obese
subgroup (n ¼ 1423) was the only prespecified cohort where the
point estimate favoured the intervention of higher energy de-
livery.17 While these results are simply hypothesis-generating,
they highlight that obese critically ill patients may respond
differently compared with leaner patients and need to be
explored further.
The results from the present study also highlight that ICU di-
etitians in ANZ who responded to the survey would recommend
additional protein (over and beyond what is provided in a standard
enteral product) in an obese patient when the daily protein deficit
is significant (30 g protein/day in the case provided). When pro-
vided, supplemental protein was reported to be given early (within
the first 10 days). Despite this practice, the clinical and functional
benefit of early and high protein supplementation in heteroge-
neous ICU patients remains unclear, with conflicting results from
both observational and randomised trials.19 Apart from the two
small trials on hypocaloric, high protein feeding, there is no evi-
dence for the benefit of delivering high amounts of protein in obese
critically ill patients. This is another major evidence gap that needs
to be addressed in future trials.
 K.J. Lambell et al. / Australian Critical Care 34 (2021) 3e8
4.1. Implications for practice and research
This survey reports the management of an obese patient based
on a hypothetical case. What clinicians report would happen in
their ICU versus what is actually delivered in practice is an entirely
different question that requires investigation. Obese patients may
be at higher nutritional risk than their nonobese counterparts for
several reasons, including the perception that the obese patient has
increased ‘nutritional reserves’. This bias was highlighted in an
observational study (n ¼ 3257), where the delay to feeding was
significantly longer in the group of obese patients (n ¼ 663) than in
patients within the healthy weight range (mean [interquartile
range] delay of 2 days [2e4] versus 2 days [1e3], respectively,
P ¼ 0.035).20 Furthermore, the identification of malnutrition in
obese patients is extremely difficult early in the ICU setting for
multiple reasons, including challenges with obtaining accurate
anthropometrical measurements and diet and weight history and
assessing muscle wasting in the context of excessive adipose
tissue.21 Both of these factors put obese patients at high nutrition
risk, and more research is required to better understand if and how
this vulnerable subgroup responds to nutrition therapy in critical
illness.
4.2. Strengths and weaknesses
This study provides preliminary insights into the manage-
ment of the nutritional needs of an obese, critically ill patient by
dietitians in ANZ, based on a pragmatic and guideline-based
scenario, with a relatively large number of dietitians partici-
pating. Furthermore, the survey was developed by two senior
academic clinical dietitians and reviewed by five critical care
dietitians to ensure face validity. Limitations of this study include
that the questions asked were not developed using a specific
survey questionnaire method and the responses were self-
reported, so we cannot be certain that they represent actual
practice, with reports that questionnaires may overestimate
adherence to guidelines.22 Finally, as the electronic survey was
conducted via email/newsletter invitations, we were not able to
capture the response rate. We also chose not to collect identi-
fying details; therefore, responses may not be representative of
all ANZ ICU dietitians.
5. Conclusion
ICU dietitians working in ANZ who responded to the
survey generally report using the ESPEN ICU guideline recom-
mendations (20e25 kcal/kg and 1.3 g protein/kg/day, adjusted body
weight) to guide energy and protein prescription in an obese crit-
ically ill adult. Prospective studies are required to confirm these
findings and to determine the response to a nutrition intervention
in this population.
Consent for publication
There are no data included in this study from individual par-
ticipants. All responses are pooled averages with no identifying
characteristics.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
7
Conflict of Interest
Emma J Ridley is an Editor of Australian Critical Care. This
manuscript has been managed throughout the review process by
Professor Andrea Marshall. This process prevents authors who also
hold an Editorial Role to influence the editorial decisions made. No
other conflicts declared.
CRediT authorship contribution statement
Kate J. Lambell: Conceptualisation, Methodology, Formal anal-
ysis, Investigation, Visualisation, Writing - original draft. Eliza G.
Miller: Formal analysis, Investigation, Writing - review & editing.
Oana A. Tatucu-Babet: Writing - review & editing. Sandra Peake:
Writing - review & editing. Emma J. Ridley: Conceptualisation,
Methodology, Supervision, Writing - review & editing.
Acknowledgements
We would like to thank Donna Goldsmith and Simone Rickerby
from the Australian and New Zealand Intensive Care Clinical Trial
Group and Maree Ferguson from Dietitian Connection for helping
to distribute the survey and all the critical care dietitians across
Australia and New Zealand who responded to the survey.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.aucc.2020.06.005.
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