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Recommendations Summary

HF: Assessment of Energy Needs (2017)

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)

    HF: Measure Resting Metabolic Rate (RMR) in Adults with Heart Failure (NYHA Classes I-IV/AHA Stages B, C and D)

    If indirect calorimetry is available, the registered dietitian nutritionist (RDN) should use a measured resting metabolic rate (RMR), which is then multiplied by a physical activity factor to estimate total energy needs in adults with heart failure (NYHA Classes I–IV/AHA Stages B, C and D). Measurement of resting metabolic rate using indirect calorimetry is more accurate than estimating resting metabolic rate using predictive equations.

    Rating: Consensus
    Conditional

    HF: Estimate Resting Metabolic Rate (RMR) in Adults with Heart Failure (NYHA Classes I - IV/AHA Stages B and C)

    If indirect calorimetry is not available, the registered dietitian nutritionist (RDN) should use 22kcal per kg actual body weight (for normally nourished patients) to 24kcal per kg actual body weight (for malnourished patients) to estimate resting metabolic rate (RMR), which is then multiplied by a physical activity factor to estimate total energy needs in adults with heart failure (NYHA Classes I–IV/AHA Stages B and C). In these patients, measured resting metabolic rate (RMR) ranged from 22kcal per kg actual body weight in normally nourished patients to 24kcal per kg actual body weight in malnourished patients.

    Rating: Fair
    Conditional

    HF: Estimate Resting Metabolic Rate (RMR) in Adults with Advanced Heart Failure (NYHA Class IV/AHA Stage D)

    If indirect calorimetry is not available, the registered dietitian nutritionist (RDN) should use 18kcal per kg actual body weight to estimate resting metabolic rate (RMR), which is then multiplied by a physical activity factor to estimate total energy needs in adults with advanced heart failure (NYHA Class IV/AHA Stage D). In these patients, the average measured resting metabolic rate (RMR) using indirect calorimetry was 1, 610kcal per day (17.69kcal per kg actual body weight).

    Rating: Consensus
    Conditional

    HF: Estimate Total Energy Needs Using RMR and Activity Factors in Adults with Heart Failure (NYHA Classes I-IV/AHA Stages B, C and D)

    The registered dietitian nutritionist (RDN) should multiply the resting metabolic rate (RMR, measured or estimated) by one of the following physical activity factors to estimate total energy needs in adults with heart failure (NYHA Classes I–IV/AHA Stages B, C and D):

    • Sedentary: 1.0 or more to less than 1.4
    • Low active: 1.4 or more to less than 1.6
    • Active: 1.6 or more to less than 1.9
    • Very active: 1.9 or more to less than 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

      Since indirect calorimetry measurements in these recommendations include disease processes related to heart failure, the inclusion of a stress factor is not needed when estimating total energy needs.

    • Conditions of Application

      The application of the recommendations HF: Measure Resting Metabolic Rate (RMR) in Adults with Heart Failure (NYHA Classes I–IV/AHA Stages B, C and D), HF: Estimate Resting Metabolic Rate (RMR) in Adults with Heart Failure (NYHA Classes I–IV/AHA Stages B and C), and HF: Estimate Resting Metabolic Rate (RMR) in Adults with Advanced Heart Failure (NYHA Class IV/AHA Stage D) depends on the availability of indirect calorimetry.

      Dietary Reference Intake (DRI) Physical Activity Levels (PAL)

      • 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 five to seven km per hour or three to four miles per hour)
      • 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 and reimbursement 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

      One positive-quality cross-sectional study was included in the evidence analysis supporting the recommendations, conducted in patients with heart failure (NYHA Classes I–IV/AHA Stages B and C) (Aquilani, Opasich et al, 2003). None of the studies were conducted in patients with advanced heart failure (NYHA Class IV/AHA Stage D).

      Heart Failure (NYHA Classes I–IV/AHA Stages B and C):
      • In patients with heart failure (NYHA Classes I–IV/AHA Stages B and C), measured resting metabolic rate (RMR) ranged from 22kcal per kg actual body weight in normally nourished patients to 24kcal per kg actual body weight in malnourished patients (Aquilani, Opasich et al, 2003). Research is needed regarding measured resting metabolic rate in patients with heart failure
      • Grade III
      Advanced Heart Failure (NYHA Class IV/AHA Stage D):
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on their measured resting metabolic rate.
      • Grade V

    • Recommendation Strength Rationale

      Conclusion statements in support of these recommendations were given Grade III and Grade V.

    • Minority Opinions

      Consensus reached.