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К вопросу об оптимизации энергетического и белкового обеспечения больных с нервной анорексией
К вопросу об оптимизации энергетического и белкового обеспечения больных с нервной анорексией
Луфт В.М., Сергеева А.М., Тявокина Е.Ю., Лапицкий А.В. К вопросу об оптимизации энергетического и белкового обеспечения больных с нервной анорексией. Consilium Medicum. 2020; 22 (6): 28–31. DOI: 10.26442/20751753.2020.6.200139
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Аннотация
Цель. Изучить энергетические траты и суточные потери азота у пациентов с нервной анорексией (НА) для разработки рекомендаций по оптимизации их субстратного обеспечения в период реабилитационной алиментации при высоком риске развития синдрома возобновленного питания (рефидинг-синдрома).
Материалы и методы. Изучены энергетические траты (непрямая калориметрия на аппарате Cosmed Quark RMR) и суточные потери азота у
69 больных женского пола с НА в возрасте от 18 до 55 лет, находившихся на лечении в соматопсихиатрическом отделении Санкт-Петербургского научно-исследовательского института скорой помощи им. И.И. Джанелидзе.
Результаты. При реалиментации больных с НА целевое оптимальное энергетическое обеспечение составляет 56–76 ккал/сут в перерасчете на фактическую или 37–50 ккал/кг в сутки на идеальную массу тела больных, а белковое обеспечение – 1,8–2,3 г/кг на фактическую или 1,2–1,4 г/кг в сутки на идеальную массу тела. При обеспечении подобного энергетического и белкового субстратного обеспечения достигается приемлемый позитивный результат в виде постепенного набора массы тела 500–1000 г в неделю.
Заключение. Нутритивно-метаболическая терапия пациентов с НА должна проводиться в режиме персонифицированной дифференцированной гипералиментации с учетом исходного трофологического статуса и адекватной метаболической переносимости постепенно возрастающей субстратной нагрузки.
Ключевые слова: нервная анорексия, метаболизм, питание.
Materials and methods. We studied energy expenditure (indirect calorimetry on Cosmed Quark RMR apparatus) and daily nitrogen loss in 69 female patients aged from 18 to 55 years in the somatopsychiatric department of the Dzhanelidze Saint Petersburg Research Institute of Emergency Medicine.
Results. During realimentation of patients with NA, the desirable amount of protein supply is 1.8–2.3 g/kg per day of actual body weight or 1.2–1.4 g/kg per day of ideal body weight. The desirable amount of energy supply is 56–76 kcal/kg per day of actual body weight or 37–50 kcal/kg per day of ideal body weight of patients. Using this strategy we achieve a positive result by gradually gaining body weight (500–1000 g per week).
Conclusions. Nutritional and metabolic support of patients with NA should be carried out in the mode of patient-specific graded hyperalimentation, considering the initial somatometric indicators of trophological status and tolerance to a gradually increasing substrate load.
Key words: anorexia nervosa, metabolism, nutrition.
Материалы и методы. Изучены энергетические траты (непрямая калориметрия на аппарате Cosmed Quark RMR) и суточные потери азота у
69 больных женского пола с НА в возрасте от 18 до 55 лет, находившихся на лечении в соматопсихиатрическом отделении Санкт-Петербургского научно-исследовательского института скорой помощи им. И.И. Джанелидзе.
Результаты. При реалиментации больных с НА целевое оптимальное энергетическое обеспечение составляет 56–76 ккал/сут в перерасчете на фактическую или 37–50 ккал/кг в сутки на идеальную массу тела больных, а белковое обеспечение – 1,8–2,3 г/кг на фактическую или 1,2–1,4 г/кг в сутки на идеальную массу тела. При обеспечении подобного энергетического и белкового субстратного обеспечения достигается приемлемый позитивный результат в виде постепенного набора массы тела 500–1000 г в неделю.
Заключение. Нутритивно-метаболическая терапия пациентов с НА должна проводиться в режиме персонифицированной дифференцированной гипералиментации с учетом исходного трофологического статуса и адекватной метаболической переносимости постепенно возрастающей субстратной нагрузки.
Ключевые слова: нервная анорексия, метаболизм, питание.
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Materials and methods. We studied energy expenditure (indirect calorimetry on Cosmed Quark RMR apparatus) and daily nitrogen loss in 69 female patients aged from 18 to 55 years in the somatopsychiatric department of the Dzhanelidze Saint Petersburg Research Institute of Emergency Medicine.
Results. During realimentation of patients with NA, the desirable amount of protein supply is 1.8–2.3 g/kg per day of actual body weight or 1.2–1.4 g/kg per day of ideal body weight. The desirable amount of energy supply is 56–76 kcal/kg per day of actual body weight or 37–50 kcal/kg per day of ideal body weight of patients. Using this strategy we achieve a positive result by gradually gaining body weight (500–1000 g per week).
Conclusions. Nutritional and metabolic support of patients with NA should be carried out in the mode of patient-specific graded hyperalimentation, considering the initial somatometric indicators of trophological status and tolerance to a gradually increasing substrate load.
Key words: anorexia nervosa, metabolism, nutrition.
Полный текст
Список литературы
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2. Lucas AR, Beard CM, O'Fallon WM, Kurland LT. 50-year trends in the incidence of anorexia nervosa in Rochester. Minn.: a population-based study. Am J Psychiatry 1991; 148 (7): 917–22.
3. Tanaka H, Kiriike N, Nagata T, Riku K. Outcome of severe anorexia nervosa patients receiving inpatient treatment in Japan: An 8-year follow-up study. Psychiatry Clin Neurosci 2001; 55: 389–96.
4. Fisher M. The course and outcome of eating disorders in adults and in adolescents: a review. Adolesc Med 2003; 14: 149–58.
5. Löwe B, Zipfel S, Buchholz C et al. Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study. Psychol Med 2001; 31: 881–90.
6. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry 2011; 68 (7): 724–31.
7. Steinhausen HC. The Outcome of Anorexia Nervosa in the 20th Century. Am J Psychiatry 2002; 159 (8): 1284–93.
8. National Institute for Clinical Excellence. Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. London: National Institute for Clinical Excellence (NICE). NICE Clinical Guidelines 2004; 9: 261.
9. National Institute for Health and Clinical Excellence, Eating disorders: recognition and treatment. London: National Institute for Clinical Excellence (NICE). NICE Clinical Guidelines 2017; 9: 40.
10. American Psychiatric Association: Treatment of patients with eating disorders. 3rd ed. Am J Psychiatry 2006; 163: 4–54.
11. Ozier AD, Henry BW. Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Other Eating Disorders. American Dietetic Association. J Am Dietetic Assoc 2011; 111 (8): 1236–41.
12. Mehler PS, Winkelman AB, Andersen DG, Gaudiani JL. Nutritional rehabilitation: practical guidelines for refeeding the anorectic patient. J Nutr Metab 2010; 1–7.
13. Basics in clinical nutrition. Editor-in-Chief Luboš Sobotka. Prague: Galen, 2019.
14. Ornstein RM, Golden NH, Jacobson MS, Shenker IR. Hypophosphatemia during nutritional rehabilitation in anorexia nervosa: implications for refeeding and monitoring. J Adolesc Health 2003; 32: 83–8.
15. Clinical nutrition guide. Pod red. V.M. Lufta. Saint Petersburg: Art-Ekspress, 2016 (in Russian).
[Parenteral and enteral nutrition. National leadership. Pod red. M.Sh. Khubutiia, T.S. Popovoi, A.I. Saltanova. Moscow: GEOTAR-Media, 2014 (in Russian).]
2. Lucas AR, Beard CM, O'Fallon WM, Kurland LT. 50-year trends in the incidence of anorexia nervosa in Rochester. Minn.: a population-based study. Am J Psychiatry 1991; 148 (7): 917–22.
3. Tanaka H, Kiriike N, Nagata T, Riku K. Outcome of severe anorexia nervosa patients receiving inpatient treatment in Japan: An 8-year follow-up study. Psychiatry Clin Neurosci 2001; 55: 389–96.
4. Fisher M. The course and outcome of eating disorders in adults and in adolescents: a review. Adolesc Med 2003; 14: 149–58.
5. Löwe B, Zipfel S, Buchholz C et al. Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study. Psychol Med 2001; 31: 881–90.
6. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry 2011; 68 (7): 724–31.
7. Steinhausen HC. The Outcome of Anorexia Nervosa in the 20th Century. Am J Psychiatry 2002; 159 (8): 1284–93.
8. National Institute for Clinical Excellence. Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. London: National Institute for Clinical Excellence (NICE). NICE Clinical Guidelines 2004; 9: 261.
9. National Institute for Health and Clinical Excellence, Eating disorders: recognition and treatment. London: National Institute for Clinical Excellence (NICE). NICE Clinical Guidelines 2017; 9: 40.
10. American Psychiatric Association: Treatment of patients with eating disorders. 3rd ed. Am J Psychiatry 2006; 163: 4–54.
11. Ozier AD, Henry BW. Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Other Eating Disorders. American Dietetic Association. J Am Dietetic Assoc 2011; 111 (8): 1236–41.
12. Mehler PS, Winkelman AB, Andersen DG, Gaudiani JL. Nutritional rehabilitation: practical guidelines for refeeding the anorectic patient. J Nutr Metab 2010; 1–7.
13. Basics in clinical nutrition. Editor-in-Chief Luboš Sobotka. Prague: Galen, 2019.
14. Ornstein RM, Golden NH, Jacobson MS, Shenker IR. Hypophosphatemia during nutritional rehabilitation in anorexia nervosa: implications for refeeding and monitoring. J Adolesc Health 2003; 32: 83–8.
15. Руководство по клиническому питанию. Под ред. В.М. Луфта. СПб: Арт-Экспресс, 2016.
[Clinical nutrition guide. Pod red. V.M. Lufta. Saint Petersburg: Art-Ekspress, 2016 (in Russian).]
________________________________________________
2. Lucas AR, Beard CM, O'Fallon WM, Kurland LT. 50-year trends in the incidence of anorexia nervosa in Rochester. Minn.: a population-based study. Am J Psychiatry 1991; 148 (7): 917–22.
3. Tanaka H, Kiriike N, Nagata T, Riku K. Outcome of severe anorexia nervosa patients receiving inpatient treatment in Japan: An 8-year follow-up study. Psychiatry Clin Neurosci 2001; 55: 389–96.
4. Fisher M. The course and outcome of eating disorders in adults and in adolescents: a review. Adolesc Med 2003; 14: 149–58.
5. Löwe B, Zipfel S, Buchholz C et al. Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study. Psychol Med 2001; 31: 881–90.
6. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry 2011; 68 (7): 724–31.
7. Steinhausen HC. The Outcome of Anorexia Nervosa in the 20th Century. Am J Psychiatry 2002; 159 (8): 1284–93.
8. National Institute for Clinical Excellence. Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. London: National Institute for Clinical Excellence (NICE). NICE Clinical Guidelines 2004; 9: 261.
9. National Institute for Health and Clinical Excellence, Eating disorders: recognition and treatment. London: National Institute for Clinical Excellence (NICE). NICE Clinical Guidelines 2017; 9: 40.
10. American Psychiatric Association: Treatment of patients with eating disorders. 3rd ed. Am J Psychiatry 2006; 163: 4–54.
11. Ozier AD, Henry BW. Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Other Eating Disorders. American Dietetic Association. J Am Dietetic Assoc 2011; 111 (8): 1236–41.
12. Mehler PS, Winkelman AB, Andersen DG, Gaudiani JL. Nutritional rehabilitation: practical guidelines for refeeding the anorectic patient. J Nutr Metab 2010; 1–7.
13. Basics in clinical nutrition. Editor-in-Chief Luboš Sobotka. Prague: Galen, 2019.
14. Ornstein RM, Golden NH, Jacobson MS, Shenker IR. Hypophosphatemia during nutritional rehabilitation in anorexia nervosa: implications for refeeding and monitoring. J Adolesc Health 2003; 32: 83–8.
15. Clinical nutrition guide. Pod red. V.M. Lufta. Saint Petersburg: Art-Ekspress, 2016 (in Russian).
Авторы
В.М. Луфт*, А.М. Сергеева, Е.Ю. Тявокина, А.В. Лапицкий
ГБУЗ «Санкт-Петербургский научно-исследовательский институт скорой помощи им. И.И. Джанелидзе», Санкт-Петербург, Россия
*lvm_aspep@mail.ru
Dzhanelidze Saint Petersburg Research Institute of Emergency Medicine, Saint Petersburg, Russia
*lvm_aspep@mail.ru
ГБУЗ «Санкт-Петербургский научно-исследовательский институт скорой помощи им. И.И. Джанелидзе», Санкт-Петербург, Россия
*lvm_aspep@mail.ru
________________________________________________
Dzhanelidze Saint Petersburg Research Institute of Emergency Medicine, Saint Petersburg, Russia
*lvm_aspep@mail.ru
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