AWM: Estimating Resting Metabolic Rate (RMR) (2014)


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.

PubMed ID: 17993767
Study Design:
Cross-Sectional Study
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

The aims of this study were to develop and cross-validate new equations for predicting resting energy expenditure (PREE) in severely-obese Italian males and to compare their accuracy with previously-published equations.

Inclusion Criteria:

Males 18 years to 60 years of age with a BMI of at least 40kg/m2, who gave written informed consent.

Exclusion Criteria:

Subjects with overt metabolic or endocrine disease (such as diabetes, hypothyroidism, hypertension, etc.) and those who were taking regular medications known to influence metabolism were excluded.

Description of Study Protocol:
  • Recruitment: Subjects were recruited from the Division of Metabolic Diseases, Italian Institute for Auxology
  • Design: Cross-sectional study
  • Blinding used: Implied with measurements.

Statistical Analysis 

  • Bland Altman analysis was used to test for bias (mean difference) and limits of agreement between measured REE (MREE) and predicted REE (PREE). For the development and cross-validation of new equations, the data set of 182 MREE values was randomly split into two groups: A calibration group (cohort 1) for development of predictive equations and a cross-validation group (cohort 2) for the validation of the predictive equations.
  • In cohort 1, simple linear regression was completed on variables related to MREE and a new equation obtained by stepwise selection
  • Bland Altman was used to cross-validate in cohort 2
  • Accuracy was defined as the percentage of subjects whose REE was predicted to within 5% of measured REE.
Data Collection Summary:

Timing of Measurements

Measurements were taken in the morning on fasting subjects.

Dependent Variables 

  • REE was measured after an overnight fast by indirect calorimetry using the SensorMedics Vmax 29, for 30 minutes (the first five to 10 minutes of adjustment were excluded from analysis)
  • REE was estimated using the following equations: Harris-Benedict, WHO/FAO/UNU, Huang, Owen, Mifflin, Livingston, Nelson, Bernstein and Cunningham.

Independent Variables 

  • BMI
  • Waist and hip circumference
  • Fat-free mass (FFM) and fat mass (FM) were measured by bioelectrical analysis.

Control Variables

  • Sex
  • Age.
Description of Actual Data Sample:
  • Initial N: 164 severely-obese males
  • Attrition (final N): 164 males
  • Age: 20 to 65 years
  • Ethnicity: Italian
  • Other relevant demographics: Not reported
  • Anthropometrics: Age, height and waist-to-hip ratio were not significantly different between the four sub-groups
  • Location: Italy.
Summary of Results:

Key Findings

  • Two new specific equations based on anthropometric REE = weight x 0.048 + height x 4.655 - age x 0.020 - 3.605 (R2, -0.68; SE, 1.14MJ) or body composition parameters REE = FFM x 0.081 + FM x 0.049 - age x 0.019 - 2.194 (R2, 0.65; SE, 1.15MJ) were generated
  • The data set of cohort 2 was used to validate the new equations
  • Mean PREE were no different from the mean measured resting energy expenditure (MREE) (over 1%, P>0.001) and REE was predicted accurately (95% to 105% of MREE) in 66% and 62% of subjects, respectively
  • The WHO/FAO/UNU, Harris Benedict, Huang and Owen equations showed mean differences lower than 5% and PREE was accurate in less than 30% of subjects
  • The Mifflin, Livingston and Nelson equations showed a mean PREE under-estimation over 7.0% (P<0.001) and PREE was accurate in less than 25% of subjects
  • The Bernstein and Cunningham equations showed a greater PREE under-estimation (over 22%, P<0.001) in more than 85% of subjects.
Author Conclusion:
  • In conclusion, these new prediction equations allow an accurate estimation of REE in groups of severely obese men and result in lower mean differences and lower limits of agreement between PREE and MREE than previous commonly-used equations
  • The equations could represent a useful tool for health care professionals who do not have access to indirect calorimetry equipment for the estimation of REE in severely-obese males.
Funding Source:
University/Hospital: Progetti di Ricerca Corrente, Italian Institute for Auxology, Milan, Italy
Reviewer Comments:

Large sample size of obese males, but age ranged from 20 to 65 years and recruitment methods were not described.

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) Yes
  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) Yes
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? ???
  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? ???
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  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? Yes
  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.) Yes
  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? N/A
  4.1. Were follow-up methods described and the same for all groups? N/A
  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%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? N/A
  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? Yes
  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.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? Yes
  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? N/A
  6.6. Were extra or unplanned treatments described? N/A
  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)? Yes
  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