Steve Klasnic

Citation: Boullata J, Williams J, Cottrell F, Hudson L, Compher C. (2007). Accurate determination of energy needs in hospitalized patients. Journal of the American Dietetic Association, 107, 393-401. Case-control study C Positive (+) To evaluate the accuracy of seven predictive equations, including the Harris-Benedict and the Mifflin equations, against measured resting energy expenditure (REE) in hospitalized patients, including patients with obesity and critical illness. All patients for whom a nutrition assessment was ordered at the Hospital of the University of Pennsylvania that year underwent indirect calorimetry and were included in this study. No diagnoses were excluded

Study Design: Class: Quality Rating: Research Purpose:

Inclusion Criteria: Exclusion Criteria: Description of Study Protool:

Patients with incomplete data sets were excluded Recruitment A retrospective evaluation of the nutrition support service REE database from 1991. Blinding used (if applicable) N/A N/A Intervention (if applicable) N/A N/A Statistical Analysis

Descriptive statistics included mean standard deviation REE values, and percent accuracy by patient subgroups Pearson's correlation was used to compare measured REE to each predictive equation Univariate and multivariate logistic regression was used to determine the odds of specific variables predicting accuracy of the given equation The variables for logistic regression included age tertile (young and older tertile compared to middle-age tertile), race (African American compared to white), sex (women compared to men), BMI category (all other categories compared to desirable weight category) and ventilator status (ventilator compared to canopy measurement) Data is presented as OR, with P values, and 95% CI. P<0.05 were considered

statistically significant. Statistical analyses were performed using SPSS

Data Collection Summary:

Timing of Measurements Energy expenditure measurements were obtained by a single respiratory therapist using a strict protocol REE was measured after a 30-minute rest, a minimum two-hour fast (unless enteral or parental feedings were infusing continuously), with no movement by the patient in a thermoneutral environment Patient height in the database was a measured value or documented in the medical record BMI was calculated The last recorded temperature on a patient's vital signs record just before the REE measurement was documented Whether or not gas measure was collected by a canopy or through attachment to a mechanical ventilator circuit. Dependent Variable Difference between the measured EE (indirect calorimetry) and the predicted EE (per equation).

Independent Variable Predictive equations: General Harris-Benedict: Men: [66.5 + (13.8)(weight) + (5)(height) - (6.8)(age)] Women: [655 + (9.6)(weight) + (1.8)(height) - (4.7)(age)] Mifflin-St. Jeor: Men: [5 + (10)(weight) + (6.25)(height) - (5)(age)] Women: [-161 + (10)(weight) + (6.25)(height) - (5)(age)] Ireton-Jones 1992: [1,925 + (5)(weight) - (10)(age) + (281)(one if ventilated; zero if not) + 292(one if trauma; zero if none) + 851(one if burned; zero if not)] American College of Chest Physicians: [(25kcal)(weight)] Obesity Ireton-Jones for obese individuals [1,444 + (606)(sex = one for male or zero for female) + (9)(weight) - (12)(age) + (400)(one if ventilated; zero if not)] Harris-Benedict using adjusted body weight [(Hamwi x 1.3)] [Men: 48.2 + (2.7)(inches of height over 5 ft)] [Women: 45.5 + (2.3)(inches of height over 5 ft)] [James x 1.3] [Men: (1.1013)(weight) - (0.01281)(BMI)(weight)] [Women: (1.07)(weight) - (0.0148)(BMI)(weight)]

Ventilated Patients Swinamer [-4,349 + (948)(BSA) - (6.4)(age) + (108)(temperature) + (24.2)(breaths per minute) + (81.7)(Liters tidal volume)] Penn State [-6,433 + (Harris Benedict)(0.85) + (minute ventilation Liters per minute)(33) + (maximum temperature)(175).]

Description of Actual Data Sample:

Initial Number: 397 Final Number: 395 Age: 16-92 years Ethnicity: 61% Caucasian (white), 36% African American, 3% Asian or Hispanic Anthropometrics: The BMI values (31 to 53) covered all National Heart, Lung, and Blood Institute classifications, but the mean value fell in the desirable weight range (BMI 245.6)

Summary of Results:

Location: Hospital of the University of Pennsylvania in Philadelphia Group: Variables Accurate Accurate Maximum Prediction Underpredictions Over s (%) (%) predictions (%) All: Harris-Benedict 43 28 78 All: Harris-Benedict 61 34 62 1:1 All: Mifflin St. Jeor 35 25 83 All: Mifflin St. Jeor 58 32 66 1.1 All: Ireton-Jones 28 29 93 1992 All: ACCP 43 32 109 Obese Obese Obese Obese Ventilated Ventilated Harris-Benedict 62 Ireton-Jonesobesity HB (Hamwi) HB (James) 32 44 46 26 35 19 14 29 15 59 46

Author Conclusion:

Swinamer 45 33 116 Penn State 43 25 56 2004 Ventilated Harris-Benedict 55 34 62 1.1 See tables 2, 3 and 4 (in article) or detailed results per group. No equation accurately predicted REE in most hospitalized patients. Without reliable predictive equation, only indirect calorimetry will provide accurate assessment of energy needs. Although indirect calorimetry is considered the standard for assessing REE in hospitalized patients, several predictive equations are commonly used in practice. Their accuracy in hospitalized patients has been questioned. This study evaluated several of these equations, and found that even the most accurate equation (Harris-Benedict 1.1) was inaccurate in 39% of patients and had an unacceptably high error rate. Indirect calorimetry may still be necessary in difficult cases to manage hospitalized patients.

Review Comments:

Strengths Only used patients histories containing complete data sets Research question and outcome stately clearly Although results were not promising for the selected methods of calculation, author was thorough in explanation of reasoning Weaknesses Limited ability to generalize since patients only studied at one location