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Energy Expenditure

EE: Benefits and Risks/Harms of Implementation (2014)

Benefits and Risks/Harms of Implementing the Recommendations

Safety issues should be considered for each recommendation. A description of the general benefits and risks associated with the implementation of this guideline must be addressed.

Failure to measure the resting metabolic rate (RMR) accurately may result in incorrect diagnosis of the energy state, inaccurate therapy for patients who want to gain or lose body weight, or overfeeding or underfeeding of healthy and non-critically ill individuals.

Not following the guideline may result in inappropriate nutrition care plans, due to inaccurate RMR measurement.

To view more information, select the link to the topic listed after each potential benefit/harm.

Potential Benefits

The primary goal of implementing these recommendations includes improving the percentage of individuals who are able to meet their nutritional needs and positively impact the patient’s treatment and clinical outcomes.

Risk/Harm Considerations

  • Clinical judgment is needed to determine if fasting is contraindicated  (EE: Fasting Requirements)
  • A four-hour abstinence from caffeine or other stimulants may be difficult for some individuals (EE: Caffeine and Stimulants)
  • Abstaining from nicotine products for more than 140 minutes may be difficult for some individuals (EE: Smoking and Nicotine).
  • When applying the recommendation to children, the child's age should be considered, due to variability in physical and developmental attributes
  • Clinical judgment should be used in applying these recommendations to individuals other than the populations specified in each recommendation, since limited evidence exists in children and across the spectrum of healthy and non-critically ill adults. 
Technical Factors That Decrease the Accuracy of Indirect Calorimetry Measurements
  • Mechanical ventilation with FIO2 ≥ 60% or unstable FIO2 (> ±0.01)
  • Mechanical ventilation with PEEP > 12 cm H2O
  • Hyperventilation or hypoventilation
  • Sampling system leak
  • Excessive moisture in the indirect calorimetry system
  • Failure to collect all expiratory flow (e.g., bronchopleural fistula, chest tube leak, etc.)
  • Supplemental oxygen in spontaneously breathing patients
  • Hemodialysis in progress
  • Calibration errors.
Reference: Matarese LE. Indirect calorimetry: technical aspects. J Am Diet Assoc. 1997 Oct; 97 (10 Suppl 2): S154-S160. Review. PMID:9336580.

Factors to Consider Before, During and After an RMR Measurement
  • Minimal physical activity (e.g., walking into facility) is acceptable prior to the rest period; beyond light intensity physical activity, see Physical Activity recommendation. (EE: Rest Period Duration). However, if an individual engages in physical activity prior to the RMR measurement, additional costs may be incurred because the measurement will need to be rescheduled. (EE: Physical Activity)
  • Movement (e.g., fidgeting) during the rest period may require extension of the rest period. See the Resting Activities recommendation. (EE: Rest Period Duration)
  • If unable to achieve a steady state, the RDN should recalibrate the instrument and take a second measurement. If steady state is still not achieved, the RDN should remeasure on a different day or in an adult, average the two measurements. [EE: Duration of Measurement (Steady State)]
  • If the rest period requirements or the steady state requirements cannot be achieved, time to complete the measurement will be prolonged or the measurement will need to be rescheduled. Additional costs may be incurred. [EE: Rest Period DurationEE: Duration of Measurement (Steady State)]
  • An overnight fast is preferred (EE: Fasting Requirements)
  • For children, if the choice is mouthpiece/noseclip vs. face mask, it has been reported that children (7 to 12 years) prefer the facemask (Mellecker and McManis, 2009) (EE: Gas Collection Devices)
  • Some face masks and mouthpiece/noseclips are disposable, so additional costs will be incurred (EE: Gas Collection Devices)
  • If an individual uses nicotine products within 140 minutes prior to the RMR measurement or consumes caffeine or other stimulant products within four hours prior to the RMR measurement, additional costs may be incurred because the measurement will need to be rescheduled. (EE: Smoking and NicotineEE: Caffeine and Stimulants)
  • The effect of alcohol, non-caloric beverages or water on RMR, independent of meals was not addressed in the recommendations. Likewise, the effect of macronutrient composition, overfeeding, etc. on RMR was not addressed. (EE: Fasting Requirements)
  • In individuals where the supine position is contraindicated (e.g., cerebral palsy, orthopnea), the RDN should use clinical judgment in determining the best position. (EE: Body Positions)
  • For research, the same time of day and type of device should be used throughout the study [EE: Gas Collection DevicesEE: Diurnal Variation (Time of Day)]
  • Seasonality has been shown to have an effect on RMR, with cold indoor room temperature resulting in greater increases in energy expenditure during the winter compared to the summer (Kashiwazaki et al, 1990; van Ooijen et al, 2004) (EE: Room Conditions)
  • Increased cost may be incurred if the RMR measurement needs to be rescheduled due to a protocol violation. [EE: Application of Respiratory Quotient (RQ)]