Back to basics: estimating energy requirements for adult hospital patients.Abstract
Predictive equations are a quick and non-invasive way to estimate a patient's energy requirements, and can be a useful tool when used appropriately. However, as with any tool, the skill and experience of the user will affect the quality of the result. This paper looks at the origins and limitations of some of the more commonly used equations. Considerations in their use and interpretation, such as the use of injury and activity factors, adjusting weight and non-protein calories, are also discussed.
Key words: basal metabolism basal metabolism: see metabolism. , energy metabolism Energy metabolism
Energy metabolism, or bioenergetics, is the study of energy changes that accompany biochemical reactions. Energy sustains the work of biosynthesis of cellular and extracellular components, the transport of ions and organic chemicals against , nutrition assessment, nutrition support nutrition support,
n intravenous nutrition or orally modified for-mulas necessitated by inability to consume a general diet; administered to malnourished individuals who cannot consume food in its original form. .
The estimation of a patient's requirements is an essential component of nutrition support, ensuring that the patient's nutritional needs are met without significant over- or underfeeding underfeeding
see malnutrition, starvation. . In everyday hospital practice, several different equations are used, often without an adequate understanding of their origins and limitations. (1,2) This can lead to significant variation in energy provision, which could have serious implications for patient care. A previous review of prediction equations concluded that none is sufficiently accurate to be useful in practice. (3) However, the reality is that equations are the most widely used method for assessing nutrition support that patients need in hospital. When used appropriately, a predictive equation can be a useful tool. Although it is not a 'magic formula' to tell us the answer, it enables us to make a good prediction as a starting point Noun 1. starting point - earliest limiting point
terminus a quo
commencement, get-go, offset, outset, showtime, starting time, beginning, start, kickoff, first - the time at which something is supposed to begin; "they got an early start"; "she knew from the for ongoing patient care. Like any tool, the equation is only as good as the person using it: skill and experience will significantly inform the use and interpretation of these prediction equations.
The body's energy expenditure is usually described as consisting of three components: the basal metabolic rate basal metabolic rate
Abbr. BMR The rate at which energy is used by an organism at complete rest, measured in humans by the heat given off per unit time, and expressed as the calories released per kilogram of body weight or per square (BMR BMR basal metabolic rate.
basal metabolic rate
n See basal metabolic rate.
basal metabolic rate. ), the energy expended ex·pend
tr.v. ex·pend·ed, ex·pend·ing, ex·pends
1. To lay out; spend: expending tax revenues on government operations. See Synonyms at spend.
2. in physical activity, and the thermic thermic /ther·mic/ (ther´mik) pertaining to heat.
pertaining to heat. effect of feeding (TEF TEF Tracheoesophageal fistula, see there ). The BMR is the minimum amount of energy required to sustain the body's essential metabolic processes. It is the value for metabolic rate Noun 1. metabolic rate - rate of metabolism; the amount of energy expended in a give period
basal metabolic rate, BMR - the rate at which heat is produced by an individual in a resting state that would be obtained when the subject first awakes (remaining relaxed, and motionless) after an overnight fast, in a thermoneutral setting. Resting metabolic rate (RMR RMR Resting Metabolic Rate
RMR Registered Merit Reporter
RMR Reliability Must-Run (electric generation plant's status to maintain grid voltage/reliability)
RMR Recurring Monthly Revenue (finance) ) approximates the BMR when it is not possible to meet all of the above conditions. It is usually measured in a subject who has fasted and has been lying quietly for at least 30 minutes before measurement. (4) The TEF is the amount of energy consumed by the body after eating, in digesting and absorbing the nutrients from food and converting them for use or storage. It can be measured using indirect calorimetry calorimetry (kăl'ərĭm`ətrē), measurement of heat and the determination of heat capacity , by comparing the BMR with energy expenditure measured (in the same conditions) after a meal. TEF is usually assumed to be about 10-15% of the BMR, but is affected by a wide range of factors, such as the subject's nutritional status nutritional status,
n the assessment of the state of nourishment of a patient or subject. and the composition of the diet. Other terms used for the TEF include: 'diet-induced thermogenesis', 'postprandial thermogenesis', and 'thermic effect of a meal'. (5) The total energy expenditure is the total of basal energy expenditure basal energy expenditure The amount of oxygen consumed while resting and fasting, extrapolated to 24 hrs, roughly equivalent to 25 kcal/kg; BEE is used to determine an individual's caloric needs; BEE is multipled by level of activity–eg, 1.2 for bed rest; 1. (BMR), the TEF and activity. Increased activity raises the total, as does increased food intake (by increasing TEF) and illness/inflammation (by increasing BMR).
The rate of energy consumption in the body changes from moment to moment, and varies between different body organs and tissues, but an individual's BMR changes very little, even over significant periods of time. (6,7) Metabolic rate measurements produce a 'snapshot' of energy expenditure over a short period, which is then used to estimate the average rate of energy expenditure for the whole day. However, the measurement period may not reflect the true energy expenditure, as there is necessarily some variation and error involved. Similarly, the energy released from food will not provide exactly the calculated amount, because of losses as unabsorbed nutrient, losses due to energy conversion inefficiencies, and losses as heat. Decreased activity and muscle mass with ageing, and smaller muscle mass in women, generally contribute to a lower energy expenditure; however, variation between individuals is significant. A group of people of the same age and sex who have similar body weight and body composition will not have identical BMRs; even when intake and activity are controlled, the variation in BMRs between different members of the group will be as much as 10%. (8)
EQUATIONS FOR ESTIMATING ENERGY REQUIREMENTS
Clearly, it would be best if it were possible to measure actual energy expenditure, rather than just estimating it. For this reason, indirect calorimetry is considered to be the 'gold standard' for assessing energy expenditure in hospitalised patients. This uses respiratory gas exchange to estimate fuel consumption, and can produce accurate results when implemented correctly by trained personnel. It is not infallible in·fal·li·ble
1. Incapable of erring: an infallible guide; an infallible source of information.
2. , however, as its results are affected by factors such as oxygen therapy, haemodynamic instability, fever, nursing care activities and difficulties obtaining a steady state. (9) It is time-intensive and requires expensive equipment, and at present, most dietitians do not have access to this method for everyday estimation of their patients' needs.
Other measurement methods are generally not useful for hospital patients. Direct calorimetry is not in wide use even for research purposes, as it measures energy expenditure by monitoring the body's heat production and requires a specially designed sealed room with tightly controlled conditions. The doubly labelled water technique is the only research method that allows energy expenditure to be estimated in free-living subjects. This uses orally administered 'heavy' water (containing stable isotopes of hydrogen and oxygen) to measure the body's carbon dioxide carbon dioxide, chemical compound, CO2, a colorless, odorless, tasteless gas that is about one and one-half times as dense as air under ordinary conditions of temperature and pressure. production as indicated by the gradual loss of the isotopes from the body over 1-3 weeks. (4) The energy expenditure can then be estimated in a similar way to that in indirect calorimetry. The time frame for doubly labelled water studies is too long for the assessment of most hospital patients, and the heavy water is expensive. As an alternative to these measurement methods, predictive equations provide a cheap, quick and non-invasive method for estimating requirements, based on the main factors that affect energy expenditure: age and sex (which both affect body composition), and body size.
Researchers developing predictive equations have attempted to validate these against measurements of energy expenditure, often using statistical regression Noun 1. statistical regression - the relation between selected values of x and observed values of y (from which the most probable value of y can be predicted for any value of x)
regression toward the mean, simple regression, regression or correlation. When assessing the literature, it should be noted that correlation does not necessarily indicate how closely the equation can estimate the patient's expenditure. For example, if an equation always produced a result that was exactly double the true energy expenditure, it would lead to dangerous over-feeding if it was used for predicting patients' requirements. Statistically, though, it is considered a perfect correlation, with a correlation coefficient Correlation Coefficient
A measure that determines the degree to which two variable's movements are associated.
The correlation coefficient is calculated as: r = 1. The correlation therefore does not indicate how useful the equation would be in practice. Validation of predictive equations should always consider residuals, limits of agreement, or other indication of fit, rather than just the correlation coefficient. (10)
Various equations have been developed for the estimation of energy requirements, but the most commonly used equations are the Harris-Benedict equation and the Schofield equation The Schofield Equation is a method of estimating the basal metabolic rate (BMR) in calories of adult men and women.
It is commonly used by dieticians as a means of estimating the total calorie intake required to maintain current body mass. . More recently developed equations have attracted attention; these include the Mifflin-St Jeor equation and the Ireton-Jones equation.
Schofield equation (11,12)
The Schofield equations are an extension of the FAO/WHO/UNU work on energy requirements (13) and, as a result, are sometimes referred to, incorrectly, as the WHO equation. (14) Having since been revised by Schofield, the equation now in use is slightly different due to the incorporation of some extra data. It is the most commonly used by Australian dietitians (1) and has been preferred, because it does not require a value for height and, therefore, introduces fewer sources of error if no measured height or weight are available. Schofield did develop an additional equation that included height, but it did not significantly increase the accuracy of the prediction when compared with the simpler equation. The Schofield equation (Table 1) estimates basal requirement. It is based on a very large data set (pooled BMR data from 114 studies, with more than 7000 healthy subjects from 23 different countries). The results may have been affected by significant differences in ambient temperatures for some of the data, and also some of the subjects were significantly underweight Underweight
An situation where a portfolio does not hold a sufficient amount of securities to satisfy the accepted benchmark of the portfolio's asset allocation strategy.
Notes: and may have been malnourished mal·nour·ished
Affected by improper nutrition or an insufficient diet. . The age and weight range of subjects is wide, but the group contains many more men than women, and a significant number (about 1000) of the subjects were young male Italian soldiers and cadets. The average subject in Schofield's data set would therefore be significantly younger, leaner and fitter than an average Australian hospital patient. This may mean that the equations overestimate o·ver·es·ti·mate
tr.v. o·ver·es·ti·mat·ed, o·ver·es·ti·mat·ing, o·ver·es·ti·mates
1. To estimate too highly.
2. To esteem too greatly. requirements (15,16) even in young healthy Australian men. (17) Other validating studies have suggested that it may overestimate for those with low requirements and underestimate for those with high requirements, deviating towards the mean for both. (14) In 1991, a British panel of experts, the Panel on Dietary Reference Values ref·er·ence values
A set of laboratory test values obtained from an individual or from a group in a defined state of health. , published a modified version of the Schofield equation for use in Britain. (18) They added data from an additional 451 European subjects, particularly from older age groups, and also excluded some of Schofield's original data which were 'collected in the tropics' and were not felt to reflect the requirements of better-nourished British people See :
British Overseas Territories . The original data set may in fact have been more appropriate for multicultural Australia; however, the modifications affect only the older (over 60 years) age group. In any case, the majority of Australian dietitians are likely to be using the original, unmodified Adj. 1. unmodified - not changed in form or character
unqualified - not limited or restricted; "an unqualified denial"
modified - changed in form or character; "their modified stand made the issue more acceptable"; "the performance of the modified aircraft equations, because these are generally the ones to be found in textbooks and other widely used resources, such as the Dietitians' Pocketbook, (19) the previous Recommended Dietary Intakes for Use in Australia (20) and the Nutrient Reference Values for Australia and New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. , which replaced it. (21)
Harris-Benedict equation (22)
This equation was developed from a single smaller study, with only 239 subjects, all healthy Americans. The participants may not be reflective of modern Australians because they were relatively young (average age 29 [+ or -] 11 years) and lean (average body mass index 21 [+ or -] 3 kg/[m.sup.2]). Repeated measurements were made in each subject, with careful attention to factors such as subject inactivity; however, the limitations of the testing conditions mean that some subjects may not have been in a true 'basal' state, leading to over-estimation of their energy needs. (8,15) The Harris-Benedict equation (Table 2) is thought to overestimate requirements in healthy people, perhaps by 5% in men or 15% in women. (23-25) A disadvantage of this equation is that it requires both weight and height, which may often not be available. However, as it remains the most commonly used equation in the world, particularly in the USA, it is essential to be familiar with it when assessing the medical literature.
Mifflin-St Jeor equation (26)
This equation used 498 healthy adult subjects with a wide range of ages and weights (about half of the subjects were obese) and measured resting metabolic rate. The equation uses actual weight, and notably it predicts significantly lower requirements when weight is very high, compared with the Schofield and Harris-Benedict equations. An advantage of the Mifflin-St Jeor equation (Table 3) is that it is very simple and easy to remember; however, like the Harris-Benedict equation, it requires values for both weight and height. Because of its wider range of subjects, it is considered to reflect the requirements of the modern US population with less estimation bias than other equations, and has recently been endorsed by the American Dietetic Association The American Dietetic Association (ADA) is the United States' largest organization of food and nutrition professionals, with nearly 65,000 members. Approximately 75 % of ADA's members are registered dietitians and about 4 % are dietetic technicians, registered. . (27) Its use may increase in those populations among whom obesity is becoming more common, but it does not yet appear to be in common use in Australia (1) and has not been subjected to as much critical scrutiny as the older equations, having been developed more recently Further research may help establish whether it will be of lasting use in practice.
Activity and injury factors
All three of the equations above were developed using healthy subjects, and may not accurately reflect the requirements of hospitalised patients. They estimate only basal or resting requirements, and therefore, it is customary to make adjustments to the value obtained, to allow for energy expended in activity and for the increased requirements due to illness. In practice, these adjustment factors are often applied in different ways. Typically, the result from the equation is multiplied by an activity factor (which may be only 1.0 for a sedated patient lying still in bed) and a stress or injury factor pertaining per·tain
intr.v. per·tained, per·tain·ing, per·tains
1. To have reference; relate: evidence that pertains to the accident.
2. to the individual patient's condition. There is no evidence to support the less-common practice of adding the activity and stress factors before multiplying by the basal energy expenditure. It may be based on different assumptions about how activity and stress would increase requirements.
The activity and stress factors were not developed by the authors of the equations, but have been suggested by researchers investigating total energy expenditure in different states of illness or exercise. Table 4 lists activity factors derived from the FAO/WHO/UNU Expert Consultation Report and from a variety of other studies, mostly in healthy people. (13,28-33) Physical activity levels (PALs) are obtained by measuring total energy expenditure in free-living individuals and dividing by their BMR. This produces a multiple of the BMR that expresses the average energy requirement for that individual's level of daily activity. When the measured energy cost of a particular activity (climbing a ladder, for example) is expressed as a multiple of BMR, this is called the physical activity ratios (PARs) for that activity. Both PALs and PARs are expressed as a multiple of the BMR, and are therefore affected by any errors in measurement of BMR and total energy expenditure. (34) The PAR and PAL values are generated from non-fasting subjects, so they include the TEF: this means that an additional factor for TEF is not necessary when using these as activity factors to predict an individual's energy requirement. Illness may have an effect on TEF: the thermic response to nutrition can be increased in stress situations, while continuous tube feeding tube feeding,
n a method for supplying liquid nutrition through a tube that passes through the nasal passages and into the stomach. This method is utilized when ingesting food through the oral cavity is inadvisable or painful due to surgery or injury. may reduce TEF close to the fasting level. (9) It is important to consider that illness and sedation Sedation Definition
Sedation is the act of calming by administration of a sedative. A sedative is a medication that commonly induces the nervous system to calm.
The process of sedation has two primary intentions. cause a decrease in activity, so the activity component of total energy expenditure is likely to be lower for a hospital patient than for a healthy person performing the same activity. For example, studies of healthy people with sedentary jobs found that their activity factor averaged 1.5-1.7, (29,35) while Elia reports a variety of studies showing activity factors of only 1.15-1.3 in free-living people with chronic illnesses, and 1.0-1.2 in hospitalised people with acute diseases. (28)
Although illness tends to cause a decrease in physical activity, it can also cause an increase in energy requirements, by several different mechanisms. For example, inflammatory or infective infective /in·fec·tive/ (in-fek´tiv)
1. capable of producing infection.
2. infectious (1).
Capable of producing infection; infectious. illness can increase the BMR. Large wounds, such as in burn injury, cause loss of heat and body tissue. A fever may increase energy expenditure by about 10% of BMR for every centigrade centigrade /cen·ti·grade/ (sen´ti-grad) having 100 gradations (steps or degrees); see under scale.
Celsius. degree above normal body temperature, (36) while inducing hypothermia hypothermia
Abnormally low body temperature, with slowing of physiological activity. It is artificially induced (usually with ice baths) for certain surgical procedures and cancer treatments. (such as after stroke or cardiac arrest cardiac arrest
Abbr. CA A sudden cessation of cardiac function, resulting in loss of effective circulation.
A condition in which the heart stops functioning. ) decreases energy expenditure. (37) Pain and stress, too, increase energy expenditure, while sedation and pain control can decrease it. Energy expenditure is reduced further with heavier sedation. (38)
Since the early studies of energy expenditure were published, changes in patient care (particularly in the critically ill) such as improved pain management and respiratory support, avoidance of overfeeding overfeeding,
n feeding behavior in which infants and children are given more food than they can optimally digest. Not as common in breastfed infants, because a mother's milk production is limited naturally. , and more effective treatment of infections, have reduced the impact of illness on energy consumption. This means that older recommendations for injury factors are mostly too high. Newer research has also revealed a surprisingly wide variation in metabolic rates of patients with conditions that were previously assumed to be consistently hypermetabolic, such as cancer (39) and sepsis Sepsis Definition
Sepsis refers to a bacterial infection in the bloodstream or body tissues. This is a very broad term covering the presence of many types of microscopic disease-causing organisms. . (40,41) Such patients may have BMRs that are close to normal, or even below normal, and even where hypermetabolism occurs, it may be short-lived, peaking within a few days. (28) Unfortunately, the injury factors that are still in wide use (and which still appear in many textbooks) are those from the original classic paper by Long et al. from 1979, (42) and use of these may significantly overestimate requirements, as indicated by more recent studies. (28,43-45) One of the more comprehensive approaches is the study by Barak et al., (43) who derived injury factors for the critically ill using indirect calorimetry and compared them with existing factors in the literature. The paper by Elia (28) is a compilation of energy expenditure data for a variety of both acute and chronic illnesses. Table 5 displays some injury factors based on these recent studies.
The studies that derived these injury factors have most commonly used the Harris-Benedict equation, and consequently it has been argued that the factors are not valid to use with other equations. However, the injury factors represent the estimated degree of hypermetabolism as a multiple of the BMR, so in theory they should be applicable to any equation that accurately estimates BMR. In reality, none of the equations is free of bias or error, and this error may be increased if the injury factors are treated as fully transferable between equations. Even with equations known to have a similar bias (such as the Schofield and Harris-Benedict equations, which both tend to overestimate BMR) conservative selection of activity and injury factors may be necessary, to avoid overfeeding. Careful evaluation of the individual patient, with attention to biochemical parameters (such as albumin, C-reactive protein C-Reactive Protein Definition
C-reactive protein (CRP) is a protein produced by the liver and found in the blood.
C-reactive protein is not normally found in the blood of healthy people. ) and clinical signs (such as body temperature, minute ventilation, cardiac output cardiac output
n. Abbr. CO
The volume of blood pumped from the right or left ventricle in one minute. It is equal to the stroke volume multiplied by the heart rate. , weight changes), can also help identify whether hypermetabolism is likely, justifying the use of a larger injury factor.
In critically ill patients, even when the energy requirement is significantly increased, it may be difficult, and even inappropriate, to meet these needs. Stress metabolism can interfere with utilisation of the extra energy, leading to an increased risk of overfeeding, and undesirable complications. (46) Conservative provision of nutrition support, or even deliberate underfeeding, is increasingly being recommended in these patients (47,48) despite their known increase in requirements.
Ireton-Jones equation (49)
This is one of the few equations available that have been developed and validated for use in hospitalised patients, rather than healthy people, and is notable for its lower estimates for heavier patients when compared with other commonly used equations. (50) The original equation (Table 6) was developed from a single study of 200 hospitalised patients, including patients with trauma and burns. Advantages of the Ireton-Jones equation include the fact that it uses the patient's actual weight, does not require a value for height, predicts total energy expenditure (therefore does not require activity or stress factors), and is subject to ongoing review by its authors and, therefore, may be more reflective of contemporary medical management than other, older equations. It takes into account specific clinical conditions, such as mechanical ventilation mechanical ventilation
A mode of assisted or controlled ventilation using mechanical devices that cycle automatically to generate airway pressure. or trauma. However, it is important to be aware of the many assumptions made in developing this equation, which affect its use and interpretation. These include:
1 A patient is critically ill only while ventilated ven·ti·late
tr.v. ven·ti·lat·ed, ven·ti·lat·ing, ven·ti·lates
1. To admit fresh air into (a mine, for example) to replace stale or noxious air.
2 All burns and trauma are of the same severity, and affect energy requirement during the ventilated/critical illness phase only. This means that the equation does not account for an anabolic anabolic
pertaining to or arising from anabolism.
steroids with a tissue-building effect. Testosterone is an example of a natural anabolic steroid with the, sometimes undesirable, effect of causing masculinization. period of convalescence convalescence /con·va·les·cence/ (kon?vah-les´ins) the stage of recovery from an illness, operation, or injury.
3 All modes of ventilation have the same impact on energy requirements.
4 All obese patients have the same body size and body composition at a given weight.
Several study groups have tested this equation on their own patients, usually by comparing the results of the equation (which estimates total energy expenditure) with indirect calorimetry measures of resting expenditure. This may be appropriate in a sedated critically ill patient, but is not a valid comparison if the patient has significant activity. Unsurprisingly, the Ireton-Jones equation produces a result that is significantly greater than the resting energy expenditure in such situations. (51,52) In a number of studies of sedated mechanically ventilated patients, the Ireton-Jones equations performed better than other equations (including the Harris-Benedict equation), but did show some bias towards underestimation. (50,53-56) Two studies of acutely ill hospital patients found that the Harris-Benedict equation used with an injury factor was more accurate than the Ireton-Jones equation. One of these studies looked at normal-weight ventilated critically ill patients (using a factor of 1.2); (55) the other was in acutely ill obese patients and used an adjusted weight value (with an injury factor of 1.3). (57)
Which value to use for body weight has been a controversial issue for some time. All of the equations discussed above were developed using the actual weight of each subject, and the authors make no recommendations regarding the use of any other value. Use of an arbitrary adjusted weight value introduces an additional source of possible error, increasing the variability of the result. (58) However, there are many situations in which the patient's weight differs significantly from normal, and the use of the actual weight value can lead to unacceptable errors in estimating requirements. (59-61) It may therefore be appropriate sometimes to use a different value in the calculation.
If the patient is underweight, the use of the patient's current weight is likely to be the best way to estimate current energy requirements. However, in some patients, such as the critically ill, this may be an underestimate. (59) If it is appropriate to aim for weight gain, ideal weight can be used to estimate an ideal energy intake. However, this approach may be too aggressive for frail or unstable patients, and it may be necessary to select a more conservative goal weight at first, particularly in very underweight people. Close monitoring is desirable to ensure that the patient does not develop overfeeding-related complications. The risk of overfeeding is increased during illness, as stress metabolism alters fuel utilisation. (46) During this time, any weight gained will be mainly fat and fluid. (62) As a guide, weight change (either gain or loss) is not an appropriate goal during the period that an injury/stress factor applies to the patient.
If the patient is overweight or obese, or severely oedematous OE`dem´a`tous
a. 1. (Med.) Pertaining to, or of the nature of, edema; affected with edema. , using the actual weight can lead to an overestimation o·ver·es·ti·mate
tr.v. o·ver·es·ti·mat·ed, o·ver·es·ti·mat·ing, o·ver·es·ti·mates
1. To estimate too highly.
2. To esteem too greatly. of the patient's requirements. The metabolic activity of adipose tissue adipose tissue (ăd`əpōs'): see connective tissue.
or fatty tissue
Connective tissue consisting mainly of fat cells, specialized to synthesize and contain large globules of fat, within a is lower compared with other tissue, (63,64) so an obese patient has a lower metabolic rate per kg body weight. It has been suggested that the ratio of lean tissue lean tissue
muscle tissue without fat. to fat tissue changes as weight increases. That is, an increase in adipose tissue is supported by an increase in muscle and organ mass but, at the point of obesity, the fat stores are increasing disproportionately. (65,66) Studies using indirect calorimetry have obtained conflicting results on this point. (23-26,43,67,68) Some suggest that the ratio of lean tissue to fat tissue remains the same as weight increases, even in obesity; others indicate that equations using actual weight can grossly overestimate requirements in the obese. Use of an adjusted weight value is clearly problematic, (69) but may still be appropriate in order to avoid overestimating the patient's requirements in cases where overfeeding is particularly undesirable. These may include situations such as:
1 Where an obese or oedematous patient is not mobilising, such as bedbound or critically ill patients. An ambulant ambulant /am·bu·lant/ (am´bu-lant) ambulatory.
Moving or walking about.
walking or able to walk. obese or oedematous patient has greater energy expenditure in everyday activities as a result of moving the extra body weight around. If the patient is not mobilising, this contribution to energy expenditure is absent.
2 Where overfeeding may be difficult to detect and is very undesirable, such as in mechanical ventilation or other respiratory compromise, or patients receiving parenteral nutrition Parenteral nutrition
Nutrition supplied intravenously, thus bypassing the patient's digestive tract entirely.
Mentioned in: Electrolyte Supplements, Necrotizing Enterocolitis
parenteral nutrition .
3 Where the patient is sedentary in the long term, and muscle is not being maintained by activity (therefore, any extra weight is more likely to be adipose tissue), such as elderly patients or those who are otherwise mobility disabled.
4 In patient groups with known reduced energy needs, such as head injury patients after the acute period.
Usually the adjustment consists of using the ideal weight plus 25-50% of the excess weight. (43,57,67) For example, a patient weighing 100 kg whose ideal weight is 60 kg would have an adjusted weight value of 70-80 kg for use in predictive equations. Ideally, the choice of weight adjustment should be based on a physical assessment of the patient's tissue stores. A very muscular patient can be 'overweight' yet be very lean, and it would be appropriate to use actual weight in predicting the energy requirement. For most patients requiring an adjusted weight calculation, an average between ideal and actual weights would be appropriate, (43,57) while in extreme adiposity adiposity /ad·i·pos·i·ty/ (ad?i-pos´i-te) obesity.
cerebral adiposity fatness due to cerebral disease, especially of the hypothalamus.
obesity. , where lean tissue stores appear depleted de·plete
tr.v. de·plet·ed, de·plet·ing, de·pletes
To decrease the fullness of; use up or empty out.
[Latin d , or in oedema oedema
see edema. , where lean tissue is not contributing to the extra weight, an even lower adjusted weight might better reflect the patient's reduced metabolic activity. (67) Using an adjusted weight value requires caution, as it increases the risk of underfeeding in overweight patients. (27) If the patient is ambulant, it may be more appropriate to use an obesity-validated equation, such as the Mifflin-St Jeor equation (if height information is available) or the Ireton-Jones equation using the obesity factor.
Total energy or 'non-protein calories'?
In the past it has been suggested (most commonly in the context of parenteral nutrition) that a patient's energy requirements should be provided as 'non-protein calories', in order to spare the protein for healing and anabolism anabolism: see metabolism. . However, predictive equations estimate the consumption rate of all energy, not just non-protein energy. If it is assumed that the estimated requirement refers only to the non-protein energy requirement, overfeeding will result, and beyond a certain point, giving extra energy will not improve protein sparing Protein sparing is the process by which the body derives energy from sources other than protein. Such sources can include fatty tissues, dietary fats and carbohydrates. Protein sparing conserves muscle tissue. at all. As long as the protein requirement is met, it is sufficient to provide the estimated energy needs as the total energy input. (70,71)
The use of predictive equations for energy requirements has many pitfalls. There is little benefit in blindly applying an equation without paying attention Noun 1. paying attention - paying particular notice (as to children or helpless people); "his attentiveness to her wishes"; "he spends without heed to the consequences"
attentiveness, heed, regard to the individual characteristics of the patient and the situation. This can affect the credibility of the nutrition support dietitian dietitian /di·e·ti·tian/ (di?e-tish´in) one skilled in the use of diet in health and disease.
di·e·ti·tian or di·e·ti·cian
A person specializing in dietetics. , attracting terms like 'mumbo-jumbo' and 'dietitian's fudge factor'. An understanding of the origins and limitations of the equations is important for any dietitian who uses them.
The complex appearance of the equations unfortunately seems to give them more authority than they deserve. An equation is not a magic formula, and will not transform incorrect or inaccurate data into a useful result. For example, using an equation with both an estimated height and an estimated weight is probably no better than just making a conservative guess about an appropriate feed rate, or approximating requirements with a simple rule of thumb (such as a 'calories-per-kilo' method). Expressing the predicted requirement as a range, rather than a fixed value, may help avoid implying an unrealistic level of accuracy.
Most importantly Adv. 1. most importantly - above and beyond all other consideration; "above all, you must be independent"
above all, most especially , it is often forgotten that the equation only provides a suggested starting point for energy provision: the aim is not just to obtain the 'right answer' at the beginning and then walk away. Ongoing monitoring of the patient is essential, and this may involve regular re-estimation of requirements and adjustment of the feeding regimen as the patient's condition changes. An equation cannot replace other forms of assessment, such as physical examination, and is no substitute for quality patient care. However, when used by an informed and experienced practitioner, predictive equations can still be a valuable and time-saving tool, and retain a role in a dietitian's evidence-based clinical practice.
The authors wish to acknowledge Kathryn Marshall, Nicola Riley and Kellie Draffin for their valuable contributions to this paper.
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WPT Wisconsin Public Television
WPT Watson Poker Tour
WPT Wonderlic Personnel Test
WPT Wavelet Packet Transform
WPT Wireless Power Transmission
WPT Windfall Profit
WPT Wireless Personal Terminal
WPT Word Processing Technician . From SDA SDA
specific dynamic action
Serotonin dopamine antagonist (SDA)
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A security analysis that uses financial information derived from company annual reports and income statements to evaluate an investment decision.
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JOP Justice of the Peace
JOP Journal of Pediatrics
JOP Jumping Off Point
JOP Joint Operating Procedure
JOP Justification for On-Site Performance
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The difference between the amount of nitrogen taken into the body and the amount excreted or lost.
n . JPEN JPEN Joint Protection Enterprise Network
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Suzie FERRIE (1) and Meagan WARD (2)
(1) Royal Prince Alfred Hospital RPA Hospital is sometimes confused with The Alfred Hospital in Melbourne, Victoria. The short form "PA Hospital" also refers to Princess Alexandra Hospital in Brisbane, Queensland. , Sydney, New South Wales New South Wales, state (1991 pop. 5,164,549), 309,443 sq mi (801,457 sq km), SE Australia. It is bounded on the E by the Pacific Ocean. Sydney is the capital. The other principal urban centers are Newcastle, Wagga Wagga, Lismore, Wollongong, and Broken Hill. , and (2) Department of Nutrition and Dietetics, Austin Health, Melbourne, Victoria, Australia
S. Ferrie, M.Nutr.Diet, APD APD atrial premature depolarization (see atrial premature complex, under complex ); pamidronate. , Critical Care Dietitian
M. Ward, M.Nutr.Diet, APD, Senior Dietitian
Correspondence: S. Ferrie, Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW NSW New South Wales
Noun 1. NSW - the agency that provides units to conduct unconventional and counter-guerilla warfare
Naval Special Warfare 2050, Australia. Email: firstname.lastname@example.org
Table 1 Schofield equation for estimating basal metabolic rate (kJ/day) (11,12) Age (years) Men Women 10-17 74 W + 2754 56 W + 2898 18-29 63 W + 2896 62 W + 2036 30-59 48 W + 3653 34 W + 3538 Original equations over 60 49 W + 2459 38 W + 2755 Modified equations 60-74 49.9 W + 2930 38.6 W + 2875 Modified equations over 75 35 W + 3434 41 W + 2610 W = weight (kg). Table 2 Harris-Benedict equation for estimating resting energy expenditure (kcal/day) (22) Men 66.5 + 13.8 W + 5.0 H - 6.8 A Women 655.1 + 9.6 W + 1.8 H - 4.7 A Coefficients are rounded to one decimal place. W = weight (kg); H = height (cm); A = age (year). Table 3 Mifflin-St Jeor equation for estimating resting energy expenditure (kcal/day) (26) Men 10 W + 6.25H - 5 A + 5 Women 10 W + 6.25H - 5 A - 161 W = weight (kg); H = height (cm); A = age (year). Table 4 Activity factors for adult hospital patients (13,28-33) resting (lying or sitting)# 1.0-1.4 X BMR lying still, sedated or asleep 0.9-1.1 lying still, conscious 1.0-1.1 bedrest (moving self around bed) 1.15-1.2 sitting out of bed long periods 1.1-1.3 mobilising occasionally on ward 1.15-1.4 sedentary/light activity (standing for long periods)# 1.4-1.6 mobilising frequently on ward 1.4-1.5 +regular, intensive physiotherapy 1.5-1.6 moderate activity (continuous movement/slow walking)# 1.6-1.8 Factors in bold were obtained in healthy, free-living people. BMR = basal metabolic rate. Note: Factors indicated with # were obtained in healthy, free-living people. Table 5 Stress/injury factors for adult hospital patients (28,43-45) Medical 1.1-1.2 (e.g. inflammatory bowel disease, liver or pancreatic disease) Surgical 1.1-1.4 (e.g. transplant, fistula) Cancer 1.1-1.4 (e.g. tumour or leukaemia) Trauma 1.2-1.4 (e.g. skeletal or head injury or minor burns) Sepsis 1.3-1.4 or other major infection Major burns 1.4-1.6 Critical illness and/or major surgery/trauma * With mechanical ventilation 1.2-1.4 * After the first week, for next 2-3 weeks (note limitations >1.6-1.8 on utilisation and risk of overfeeding) Table 6 Ireton-Jones equation for estimating total energy expenditure (kcal/day) (49) Non-ventilated patients 629 - 11 A + 25 W - 609 O Ventilated patients 1784 - 11 A + 5 W + 244 S + 239 T + 804 B A = age (year); W = weight (kg). O = 1 if obese (body mass index > 27); 0 otherwise. S = 1 if patient is male; 0 otherwise. T = 1 if trauma (include major surgery) is present; 0 otherwise. B = 1 if burns are present; 0 otherwise.