Practice Consideration
A study assessing the accuracy of energy prediction equations for obese and non-obese older adults (60 to 82 years) is available in the Academy of Nutrition and Dietetics Evidence Analysis Library (EAL). The research addressed four widely-used equations: Owen, WHO/FAO, Harris-Benedict and Mifflin-St Jeor.(1) When compared with the subjects’ actual measured energy needs, the estimates generated from the equations were found to contain a high error rate. These initial under- and over-estimations derived from the predictive equations are further compounded when multiplied by physical activity, injury, disease or nutritional stress factors.
The study concluded that the equations are not reliable; they each fail the subject in a way that is clinically relevant. The authors recommend that calorimetry rather than predictive equations be used to estimate energy requirements. If calorimetry is not available then the recommended equation is the Mifflin-St Jeor.
| Mifflin-St Jeor | Harris-Benedict (Using Actual Body Weight)* |
Owen | WHO/FAO/Schofield | |
| (Grade II—Fair) | (Grade I—Good) | (Grade III—Limited) | (Grade III—Limited) | |
| Men | Underestimates by 18% to overestimates by 5% |
Underestimates by 19% to overestimates by 9% |
There is no individual error range |
Underestimates by 17% to overestimates by 7% |
| Women | Underestimates by 31% to overestimates 7% |
Underestimates by 27% to overestimates by 12% |
Caucasian women, underestimates by 27% to overestimates by 12% |
Underestimates by 8% to overestimates by 12% |
* Harris-Benedict using adjusted body weight was not reported in this population.
A Note on Injury Factors
The injury factors found in published research vary. The factors included in the EAL are:
- Minor surgery and cancer — 1.1 and 1.2
- Major trauma or surgery — 1.35
- Severe infection — up to 1.6(2)
There is other research that questions the applicability of an additional stress-factor for cancer patients at lower stages of the disease (Stage 1). It proposes that their energy needs are the same as those of adults without cancer. The ESPEN guidelines indicate that this will usually be within the range of 25-30 kcal/kg/day (low evidence). This may require an adjustment in more serious disease states, however often the total energy requirement (TEE) may remain relatively constant with increases in resting energy expenditure (REE) being offset by decreases in energy from physical activity as the condition becomes more advanced.(3,4,5)
The dietitian uses clinical judgment to determine which injury/disease factor to apply based on the patient’s current intake, recent weight change and the severity of the disease. The initial estimate is re-assessed at follow-up consultations by comparing diet and weight change.
References
1. Academy of Nutrition and Dietetics. Critical Illness: Determination of Resting Metabolic Rate. Individual Predictive Equations. 2006; USA: Accessed 13 August 2017. Available from: https://www.andeal.org/topic.cfm?menu=5299&cat=1071.
2. Academy of Nutrition and Dietetics. Critical Illness: Determination of Resting Metabolic Rate. Individual Predictive Equations. USA: Academy of Nutrition and Dietetics 2006; Accessed 13 August 2017. Available from: http://www.andeal.org/topic.cfm?cat=5420&conclusion_statement_id=250611&highlight=critical%20illness&home=1.
3. Reeves MM, Battistutta D, Capra S, Bauer J, Davies PS. Resting Energy Expenditure in Patients with Solid Tumors Undergoing Anticancer Therapy.
Nutrition. 2006; 22: 609-615.
4. Johnson G, Salle A, G L, et al. Cancer cachexia: Measured and predicted resting energy expenditures for nutritional needs evaluation. Nutrition. 2008; 24: 443-450.
5. Arends et al. ESPEN guidelines on nutrition in cancer patients. Clinical Nutrition 2016 (1-38) Available at: http://www.espen.info/wp/wordpress/wp-content/uploads/2016/11/ESPEN-cancer-guidelines-2016-final-published.pdf. Accessed 1 December 2017.