AWM: Monitor and Evaluate Energy Intake and Energy Needs 2014
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
AWM: Monitor and Evaluate Energy Intake and Nutrient Content
For weight loss and weight maintenance, the registered dietitian nutritionist (RDN) should monitor and evaluate energy intake and nutrient content and consider adjusting the selected caloric reduction strategy (if necessary):
- Prescribe 1, 200kcal to 1, 500kcal per day for women and 1, 500kcal to 1, 800kcal per day for men (kcal levels are usually adjusted for the individual's body weight)
- Prescribe 500kcal per day or 750kcal per day energy deficit
- Prescribe one of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low-fiber foods or high-fat foods) in order to create an energy deficit by reduced food intake.
Several studies report changes in nutrient adequacy with caloric restriction. However, the extent of nutrient inadequacy and the nutrients affected are dependent on the composition of the diet followed, as well as on the nutritional needs of the individual. Limited research reports reductions in nutrient adequacy with weight loss through an energy restriction of at least 500kcal per day or daily consumption below 1, 200kcal per day.
AWM: Monitor and Evaluate Total Energy Needs
For weight loss and weight maintenance, the RDN should monitor and evaluate total energy needs and consider one of the following (if necessary):
- Re-measure resting metabolic rate (RMR) using indirect calorimetry, since measurement of RMR using indirect calorimetry is more accurate than estimating resting metabolic rate using predictive equations
- Re-calculate Mifflin-St. Jeor, since the majority of research reviewed supports the use of the Mifflin-St. Jeor equation (using actual body weight) to predict RMR in overweight or obese adults because it demonstrated good accuracy and correlation with indirect calorimetry
- Re-apply a new physical activity factor to RMR (measured or estimated) to estimate total energy needs:
- Sedentary: 1.0 to 1.4
- Low active: 1.4 to 1.6
- Active: 1.6 to 1.9
- Very active: 1.9 to 2.5.
Risks/Harms of Implementing This Recommendation
Conditions of Application
Monitoring and evaluation of energy intake and energy needs may take place if goals have not been met, after 15 lbs to 20 lbs of weight loss or if physical activity level changes.
Energy intake and nutrient content may be assessed through the use of one of the following tools
- Food frequency questionnaires
- Three-day, four-day or seven-day food records (including weekdays and weekend days)
- 24-hour dietary recalls
- Typical daily dietary intake.
- Consider including a variety of foods
- Consider a vitamin and mineral supplement when appropriate
- Consider increasing physical activity rather than further caloric restriction
- Consider extending the weight loss timeframe to reach goal weight.
The application of the recommendation may depend on the availability of indirect calorimetry.
Mifflin-St. Jeor Equations
- Males: RMR (kcal per day) = 10 x weight (kg) + 6.25 x height (cm) - 5 x age (years) + 5
- Females: RMR (kcal per day ) = 10 x weight (kg) + 6.25 x height (cm) - 5 x age (years) - 161.
- Sedentary: Typical daily living activities (e.g., household tasks, walking to the bus)
- Low active: Typical daily living activities plus 30 to 60 minutes of daily moderate activity (e.g., walking at 5.0km to 7.0km per hour or 3.0mph to 4.0mph)
- Active: Typical daily living activities plus at least 60 minutes of daily moderate activity
- Very active: Typical daily living activities plus at least 60 minutes of daily moderate activity plus an additional 60 minutes of vigorous activity or 120 minutes of moderate activity.
Potential Costs Associated with Application
- Costs of medical nutrition therapy (MNT) sessions vary, however, MNT sessions are essential for improved outcomes.
- If applicable, costs of equipment and staff time with the use of indirect calorimetry may be additional.
- Several studies report changes in nutrient adequacy with caloric restriction, however the extent of nutrient inadequacy and the nutrients affected are dependent on the composition of the diet followed as well as on the nutritional needs of the individual (Ma et al, 2007; Truby et al, 2008)
- Limited research reports reductions in nutrient adequacy with weight loss through an energy restriction of at least 500kcal per day or daily consumption below 1, 200kcal per day (Ashley et al, 2007; Noakes et al, 2004; Gardner et al, 2010)
- Additional long-term studies in this area are needed
- The majority of research reviewed supports the use of the Mifflin-St. Jeor equation (using actual body weight) to predict RMR in overweight or obese adults because it demonstrated good accuracy and correlation with indirect calorimetry (Scalfi et al, 1993; Frankenfield et al, 2003; St. Jeor et al, 2004; Weijs, 2008; Skouroliakou et al, 2009; Weijs and Vansant, 2010; Ruiz et al, 2011; de Oliveira et al, 2012; Faria et al, 2012)
- Other equations evaluated did not predict resting metabolic rate as accurately as the Mifflin-St. Jeor equation (Heshka et al, 1993; Scalfi et al, 1993; Siervo et al, 2003; Livingston and Kohlstadt, 2005; Lazzer, Agosti, Resnik et al, 2007; Lazzer, Agosti, Silvestri et al, 2007; Skouroliakou et al, 2009; Spears et al, 2009; Weijs and Vansant, 2010; Horie et al, 2011; Ruiz et al, 2011; de Oliveira et al, 2012)
From AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults (2013)Diets for Weight Loss (Dietary Strategies for Weight Loss)
- 3a. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss as part of a comprehensive lifestyle intervention. Any one of the following methods can be used to reduce food and calorie intake:
- a. Prescribe 1, 200kcal to 1, 500kcal per day for women and 1, 500kcal to 1, 800kcal per day for men (kcal levels are usually adjusted for the individual's body weight)
- b. Prescribe a 500kcal per day or 750kcal per day energy deficit
- c. Prescribe one of the evidence-based diets that restrict certain food types (such as high-carbohydrate foods, low-fiber foods or high-fat foods) in order to create an energy deficit by reduced food intake.
- NHLBI Grade A (Strong). ACC/AHA Level of Evidence Grade A.
Recommendation Strength Rationale
- The Conclusion Statement in support of this recommendation received Grades I and II
- ACC/AHA/TOS recommendations either given NHLBI Grade A (strong), ACC/AHA Level of Evidence Grade A. Recommendation 3a was based on Critical Question 3, which analyzed systematic reviews and meta-analyses (the literature search included those published from January 2000 to October 2011) and added major RCTs published after 2009 with greater than 100 people per treatment arm.
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
What is the relationship between nutrient adequacy and caloric restriction (assuming a food-based diet without vitamin or mineral supplementation)?
In overweight or obese adults, which predictive equation for estimating resting metabolic rate should be used?
Ashley JM, Herzog H, Clodfelter S, Bovee V, Schrage J, Pritsos C. Nutrient adequacy during weight loss interventions: A randomized study in women comparing the dietary intake in a meal replacement group with a traditional food group. Nutrition Journal 2007; 6: 12.
Gardner CD, Kim S, Bersamin A, Dopler-Nelson M, Otten J, Oelrich B, Cherin R. Micronutrient quality of weight-loss diets that focus on macronutrients: results from the A TO Z study. Am J Clin Nutr. 2010; 92 (2): 304-312.
Ma Y, Pagoto SL, Griffith JA, Merriam PA, Ockene IS, Hafner AR, Olendzki BC. A dietary quality comparison of popular weight-loss plans. J Am Diet Assoc. 2007; 107 (10): 1,786-1,791.
Noakes M, Foster PR, Keogh JB, Clifton PM. Meal replacements are as effective as structured weight-loss diets for treating obesity in adults with features of metabolic syndrome. J Nutr 2004; 134(8): 1894-1899.
Truby H, Hiscutt R, Herriot AM, Stanley M, Delooy A, Fox KR, Baic S, Robson PJ, Macdonald I, Taylor MA, Ware R, Logan C, Livingstone M. Commercial weight loss diets meet nutrient requirements in free living adults over 8 weeks: a randomised controlled weight loss trial. Nutr J. 2008; 7: 25.
de Oliveira FC, Alves RD, Zuconi CP, Ribeiro AQ, Bressan J. Agreement between different methods and predictive equations for resting energy expenditure in overweight and obese Brazilian men. J Acad Nutr Diet. 2012; 112(9): 1,415-1,420.
Faria SL, Faria OP, Menezes CS, de Gouvea HR, de Almeida Cardeal M. Metabolic profile of clinically severe obese patients. Obes Surg. 2012; 22(8): 1,257-1,262.
Frankenfield DC, Rowe WA, Smith JS, Cooney RN. Validation of several established equations for resting metabolic rate in obese and non-obese people. J Am Diet Assoc. 2003; 103: 1,152-1,159.
Heshka S, Feld K, Yang MU, Allison DB, Heymsfield SB. Resting energy expenditure in the obese: A cross-validation in the obese: A cross-validation and comparison of prediction equations. J Am Diet Assoc. 1993; 93 (9): 1,031-1,036.
Horie LM, Gonzalez MC, Torrinhas RS, Cecconello I, Waitzberg DL. New specific equation to estimate resting energy expenditure in severely obese patients. Obesity (Silver Spring). 2011; 19(5): 1,090-1,094.
Lazzer S, Agosti F, Silvestri P, Derumeaux-Burel H, Sartorio A. Prediction of resting energy expenditure in severely obese Italian women. J Endocrinol Invest. 2007; 30 (1): 20-27.
Lazzer S, Agosti F, Resnik M, Marazzi N, Mornati D, Sartorio A. Prediction of resting energy expenditure in severely obese Italian males. J Endocrinol Invest. 2007; 30 (9): 754-761.
Livingston EH, Kohlstadt I. Simplified resting metabolic rate - predicting formulas for normal-sized and obese individuals. Obes Res. 2005; 13 (7): 1,255-1,262.
Ruiz JR, Ortega FB, Rodriguez G, Alkorta P, Labayen I. Validity of resting energy expenditure predictive equations before and after an energy-restricted diet intervention in obese women. PLoS One. 2011; 6(9): e23759.
Scalfi L, Coltorti A, Sapio C, DiBiase G, Borrelli R, Contaldo F. Predicted and measured resting energy expenditure in healthy young women. Clin Nutr. 1993; 12: 1-7.
Siervo M, Boschi V, Falconi C. Which REE prediction equation should we use in normal-weight, overweight and obese women? Clin Nutr. 2003; 22(2): 193-204.
Skouroliakou M, Giannopoulou I, Kostara C, Vasilopoulou M. Comparison of predictive equations for resting metabolic rate in obese psychiatric patients taking olanzapine. Nutrition. 2009; 25(2): 188-193.
Spears KE, Kim H, Behall KM, Conway JM. Hand-held indirect calorimeter offers advantages compared with prediction equations, in a group of overweight women, to determine resting energy expenditures and estimated total energy expenditures during research screening. J Am Diet Assoc 2009; 109 (5): 836-845.
St. Jeor ST, Cutter GR, Perumean-Chaney SE, Hall SJ, Herzog H, Bovee V. The practical use of charts to estimate resting energy expenditure in adults. Topics in Clinical Nutrition 2003;19:51-56.
Weijs PJ. Validity of predictive equations for resting energy expenditure in US and Dutch overweight and obese class I and II adults aged 18-65 years. Am J Clin Nutr. 2008; 88(4): 959-970.
Weijs PJ, Vansant GA. Validity of predictive equations for resting energy expenditure in Belgian normal weight to morbid obese women. Clin Nutr. 2010; 29(3): 347-351.
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett DR Jr, Tudor-Locke C, Greer JL, Vezina J, Whitt-Glover MC, Leon AS. 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc. 2011; 43(8): 1, 575-1, 581.
Jensen MD, Ryan DH, Apovian CM, Loria CM, Ard JD, Millen BE, Comuzzie AG, Nonas CA, Donato KA, Pi-Sunyer FX, Hu FB, Stevens J, Hubbard VS, Stevens VJ, Jakicic JM, Wadden TA, Kushner RF, Wolfe BM, Yanovski SZ, 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults, Journal of the American College of Cardiology. 2013; doi:10.1016/j.jacc.2013.11.004.
Otten JJ, Hellwig JP, Meyers LD, editors. Institute of Medicine/National Academy of Sciences. The Essential Guide to Nutrient Requirements, 2006. Accessed at http://www.nal.usda.gov/fnic/DRI/Essential_Guide/DRIEssentialGuideNutReq.pdf.
Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services, 2008.