Hospitalized (Non-ICU) Adults (2010-2012)

Study Design:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:
  1. To identify energy expenditure, caloric requirements, and weight changes in rehabilitation SCI patients.
  2. To compare these with values predicted by standard formulae (Harris-Benedict, Quebbeman, and Spanier and Shizgal equations).
Inclusion Criteria:
  • Patients who were more than three weeks of post injury and who were actively participating in rehabilitation.
Exclusion Criteria:
  • Those with intercurrent infection, such as fever, tachycardia, decubitus ulcers, and unexplained illness, were excluded.
Description of Study Protocol:

Recruitment:  methods not specified - patients from Department of Surgery and Rehabilitation Medicine.

Design:  Cross-Sectional Study. 

Blinding used (if applicable):  not applicable

Intervention (if applicable)

  • 45 measurements of clinical, anthropometric, and biochemical parameters of nutrition and energy expenditures by indirect calorimetry were made on SCI patients.

Statistical Analysis

  • Energy expenditure and caloric intake were than compared with the estimated values from standardized formula (using student’s t-test).
Data Collection Summary:

Timing of Measurements

Measurements made between 7 and 8 am.  Energy expenditure measured and compared to that using standard equations.

Dependent Variables

  • Energy expenditure measured through indirect calorimetry using a Beckman Metabolic Measuring Cart
  • Nitrogen excretion measured through 24-hour urine collections

Independent Variables

  • Patients received uncontrolled diet
  • Dietitian made estimates of caloric intake by dietary history of food consumed

Control Variables

Description of Actual Data Sample:

Initial N:  22 SCI patients: 19 males, 3 females.

Attrition (final N): As above   

Age:  mean age 29.8 years (range 14 - 58) 

Ethnicity: Not mentioned.

Other relevant demographics

Anthropometrics: 15 quadriplegic, 5 paraplegic, and 2 with Brown-Sequard syndrome

Location: Pennsylvania

Summary of Results:

 Other Findings

  1. Energy expenditure measured by indirect calorimetry was 19.5 kcal/kg/day.
  2. Quadriplegics and paraplegics consumed energy at different rates. Quadriplegics require 22.7 kcal/kg/day, and paraplegics 27.9 kcal/kg/day.
  3. All patients lost weight immediately after injury. Average weight loss was 8.8 kg for the whole group.
  4. On uncontrolled diet with a mean caloric intake of 1,774 calories per day, the group as a whole gained weight at a mean of 1.7 kg/wk.
Author Conclusion:

Stable rehabilitating SPI patients require 23.4 kcal/kg/day.
22.7 kcal/kg/day
27.9 kcal/kg/day

This represents 45-90% of the recommended calories for maintenance, as calculated by any of formulae, based on normal height, weight, age, and sex, when using either current weight or ideal body weight.

All patients experienced initial weight loss. The initial weight loss appeared inevitable in spite of apparently adequate nutrition support.

On uncontrolled diet, patients gained an average of 1.7kg/wk and this was also greater in the quadriplegic group.

Funding Source:
University/Hospital: thomas Jefferson University
Reviewer Comments:
  • Limited patent numbers in paraplegic group. Estimated caloric requirements in this group may not be valid.
  • The recommendations are scientifically linked to the nutrition intervention.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) N/A
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? Yes
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.6. Were extra or unplanned treatments described? Yes
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? N/A
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes