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Recommendations Summary

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.


  • Recommendation(s)

    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.

    Rating: Strong
    Imperative

    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.
    The Dietary Reference Intakes (DRI) Physical Activity Levels (PAL) represent the ratio of total energy expenditure to basal energy expenditure and are defined as sedentary, low active, active or very active.

    Rating: Consensus
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • 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.
      Strategies to achieve nutrient adequacy may include
      • 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.
      Dietary Reference Intake Physical Activity Levels
      • 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.

    • Recommendation Narrative

      • 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.

    • Minority Opinions

      Consensus reached.