Prediction of Resting Metabolic Rate in Critically Ill Patients at the Extremes of Body Mass Index

Background: Although estimation of energy needs by mathematical equation is common in practice, there is relatively little validation data for the equations. This is especially true at the upper and lower extremes of body size. The purpose of the current study was to provide validation data for several common equations in underweight and morbidly obese critically ill patients. Methods: In mechanically ventilated, critical care patients with body mass index ≤21.0 or ≥45.0 kg/m², indirect calorimetry was used to measure resting metabolic rate. Several equation methods were then compared with these measurements, including the Penn State equation, Faisy equation, Ireton‐Jones equation, Mifflin–St Jeor equation, Harris‐Benedict equation, and American College of Chest Physicians (ACCP) standard using ideal, actual, or metabolically active body weight. Results: Accuracy (percentage of estimates falling within 10% of measured) in the morbidly obese group was highest for the Penn State equation (76%) and lowest for the ACCP standard using actual body weight (0%). For the underweight group, the Penn State equation was accurate 63% of the time, but below a body mass index of 20.5, the accuracy rate dropped to 58%. No other equation was more accurate than this in the underweight patients. Conclusion: The Penn State equation is valid in morbid obesity, but the accuracy rate is much lower in underweight critically ill patients. A modification to the equation is suggested to improve accuracy in this group.     

Longitudinal Prediction of Metabolic Rate in Critically Ill Patients

Background: Indirect calorimetry is the criterion method for assessment of energy expenditure in critically ill patients but is decidedly uncommon. Thus, calculation methods proliferate. Even if indirect calorimetry is available, it usually is not repeated more than weekly on the same patient, creating potential for error. The purpose of the current study was to quantify estimation errors against indirect calorimetry measurements in critically ill patients over time. Methods: In mechanically ventilated, critical care patients, indirect calorimetry was used to measure resting metabolic rate for 7 days. Three estimation methods were compared with the cumulative measurement: the Penn State equations, the American College of Chest Physicians (ACCP) standard (25 kcal/kg body weight), and an extrapolated value based on the first measurement multiplied by 7 days. Results: The cumulative difference between measured resting metabolic rate and the rate predicted by the Penn State equations was ?468 ± 642 kcal (–3.7% ± 5.1% of the measured value). The difference for the ACCP was smaller, but variation was much wider (–387 ± 1597 kcal or ?2.2% ± 11.9% of the measured value). The extrapolated value was ?684 ± 1731 kcal (–4.1% ± 11.4% of measured expenditure). Conclusion: On average, the Penn State equations predict resting metabolic rate over time within 5% of the measured value. This performance is similar to the practice of making 1 measurement and extrapolating it over 1 week. The ACCP method has an unacceptably wide limit of agreement.     

Analysis of Estimation Methods for Resting Metabolic Rate in Critically Ill Adults

Background: Prediction of metabolic rate is an important part of the nutrition assessment of critically ill patients, yet there are limited data regarding the best equation to use to make this prediction. Methods: Standardized indirect calorimetry measurements were made in 202 ventilated, adult critical care patients, and resting metabolic rate was calculated using the following equations: Penn State equation, Faisy, Brandi, Swinamer, Ireton‐Jones, Mifflin, Mifflin × 1.25, Harris Benedict, Harris Benedict × 1.25, Harris Benedict using adjusted weight for obesity, and each of the adjusted weight versions of Harris Benedict × 1.25. The subjects were subgrouped by age and obesity status (young nonobese, young obese, elderly nonobese, elderly obese). Performance of each equation was assessed using bias, precision, and accuracy rate statistics. Results: Accuracy rates in the study population ranged from 67% for the Penn State equation to 18% for the weight‐adjusted Harris Benedict equation (without multiplication). Within subgroups, the highest accuracy rate was 77% in the elderly nonobese using the Penn State equation and the lowest was 0% for the weight‐adjusted Harris Benedict equation. The Penn State equation was the only equation that was unbiased and precise across all subgroups. The obese elderly group was the most difficult to predict. Therefore, a separate regression was computed for this group: Mifflin(0.71) + Tmax(85) + Ve(64) – 3085. Conclusions: The Penn State equation provides the most accurate assessment of metabolic rate in critically ill patients if indirect calorimetry is unavailable. An alternate form of this equation for elderly obese patients is presented, but has yet to be validated.     

Toward the Development of Predictive Equations for Resting Metabolic Rate in Acutely Ill Spontaneously Breathing Patients

Background: There are many equations used for calculating energy needs of nutrition support patients but few developed specifically for the subset of spontaneously breathing acutely ill patients. The purpose of the current study was to validate existing equations and to start developing new equations for this cohort. Methods: Acutely ill patients not requiring mechanical ventilation had their resting metabolic rate measured using an indirect calorimeter. Metabolic rate was also calculated using the Mifflin–St Jeor equation, the Ireton‐Jones equation for spontaneously breathing patients, and a modification of the Penn State equation in which the minute ventilation‐dependent variable was removed. These calculated values were compared with measured expenditure and considered accurate if they fell within 10% of the measurement. Results: Fifty‐five patients were measured successfully. The modified Penn State equation was accurate in 71% of patients compared with 44% for Ireton‐Jones and 42% for Mifflin–St Jeor. Several forms of a new equation were outlined but not validated. The equation with the highest R² (0.82) was as follows: resting metabolic rate (kcal/d) = weight in kg (20) ? age in years (3) + male sex (197) + body mass index in kg/m² (25.9) + mean heart rate in beats/min (9.4) + 89. Conclusions: A modification of the Penn State equation for predicting resting metabolic rate was shown to accurately predict resting metabolic rate in acutely ill, spontaneously breathing patients if body mass index was ≥20.5 kg/m². A new set of population‐specific equations was outlined but should not be used until validated.     

Comparison of Resting Energy Expenditure Prediction Methods With Measured Resting Energy Expenditure in Obese,Hospitalized Adults

Background: Several methods are available to estimate caloric needs in hospitalized, obese patients who require specialized nutrition support; however, it is unclear which of these strategies most accurately approximates the caloric needs of this patient population. The purpose of this study was to determine which strategy most accurately predicts resting energy expenditure in this subset of patients. Methods: Patients assessed at high nutrition risk who required specialized nutrition support and met inclusion and exclusion criteria were enrolled in this observational study. Adult patients were included if they were admitted to a medical or surgical service with a body mass index ≥ 30 kg/m². Criteria excluding patient enrollment were pregnancy and intolerance or contraindication to indirect calorimetry procedures. Investigators calculated estimations of resting energy expenditure for each patient using variations on the following equations: Harris‐Benedict, Mifflin–St. Jeor, Ireton‐Jones, 21 kcal/kg body weight, and 25 kcal/kg body weight. For nonventilated patients, the MedGem handheld indirect calorimeter was used. For ventilated patients, the metabolic cart was used. The primary endpoint was to identify which estimation strategy calculated energy expenditures to within 10% of measured energy expenditures. Results: The Harris‐Benedict equation, using adjusted body weight with a stress factor, most frequently estimated resting energy expenditure to within 10% measured resting energy expenditure at 50% of patients. Conclusion: Measured energy expenditure with indirect calorimetry should be employed when developing nutrition support regimens in obese, hospitalized patients, as estimation strategies are inconsistent and lead to inaccurate predictions of energy expenditure in this patient population.     

A Disciplined Approach to Spiritual Care Giving for Adults Living with Cystic Fibrosis

SUMMARY

Adults living with cystic fibrosis are less likely than other pulmonary patients to describe themselves as religious, to attend worship services regularly, to use god language, to describe their spiritual life, and in general, to give any obvious, outward indications of their spiritual strength, concerns, and depth. And yet, they have consistently demonstrated in chaplain-patient encounters an awareness of the function and importance of their spirituality in relation to life choices, coping with illness, facing mortality, and expressing life meaning, beliefs, and values. A disciplined approach by chaplains is a key component to engaging these patients so that each person's unique spiritual story unfolds. Results from The Discipline demonstrate how adults with cystic fibrosis are different in their expression and approach to spirituality from other pulmonary patients.     

Estimation of Resting Energy Expenditure Using Predictive Equations in Critically Ill Children: Results of a Systematic Review

Provision of adequate energy intake to critically ill children is associated with improved prognosis, but resting energy expenditure (REE) is rarely determined by indirect calorimetry (IC) due to practical constraints. Some studies have tested the validity of various predictive equations that are routinely used for this purpose, but no systematic evaluation has been made. Therefore, we performed a systematic review of the literature to assess predictive equations of REE in critically ill children. We systematically searched the literature for eligible studies, and then we extracted data and assigned a quality grade to each article according to guidelines of the Academy of Nutrition and Dietetics. Accuracy was defined as the percentage of predicted REE values to fall within ±10% or ±15% of the measured energy expenditure (MEE) values, computed based on individual participant data. Of the 993 identified studies, 22 studies testing 21 equations using 2326 IC measurements in 1102 children were included in this review. Only 6 equations were evaluated by at least 3 studies in critically ill children. No equation predicted REE within ±10% of MEE in >50% of observations. The Harris–Benedict equation overestimated REE in two‐thirds of patients, whereas the Schofield equations and Talbot tables predicted REE within ±15% of MEE in approximately 50% of observations. In summary, the Schofield equations and Talbot tables were the least inaccurate of the predictive equations. We conclude that a new validated indirect calorimeter is urgently needed in the critically ill pediatric population.)     

Oral Nutritional Supplements in Adults with Cystic Fibrosis: Effects on Intake,Levels of Fat-Soluble Vitamins,and Bone Remodeling Biomarkers

Background: The use of oral nutritional supplements (ONS) is common practice in patients suffering from cystic fibrosis (CF). We aimed to describe the rate of ONS use to assess their contribution to dietary intake and to determine if they are associated with respiratory status, body composition, muscle strength, bone mineral density (BMD), bone remodeling biomarkers, and plasmatic levels of vitamins. Methods: Cross-sectional study. Patients were clinically stable adults recruited from the CF unit. A 4-day prospective dietary questionnaire was conducted; in addition to respiratory variables, body composition, and BMD (through densitometry, DXA), muscle strength (JAMAR dynamometer), fat-soluble vitamins, and bone remodeling biomarkers (vitamins A, D, and E; osteocalcin, OC; undercarboxylated osteocalcin, ucOC; degradation of the C-terminal telopeptides of type I collagen, CTX; and receptor activator of nuclear factor-kappaB ligand, RANKL) were also evaluated. Results: The study included 59 subjects with CF (57.6% female, mean age 29.3 ± 9.4 years, and BMI 22.0 ± 3.6 kg/m²). In this study, 22% (13) patients were taking ONS and presented, compared with those not taking them, significantly more total and mild exacerbations and lower BMI; moreover, they showed a significantly higher total daily calorie intake in addition to a higher consumption of carbohydrates, proteins, and lipids per kg of body weight, omega-3 fatty acids, and vitamins A, D, and E. Vitamin E plasmatic levels were significantly higher in the group on ONS, as was the case with RANKL; finally, a lower rate of vitamin D deficiency was also found. Conclusions: ONS were used by patients with worse respiratory and nutritional statuses and their use was associated with a higher intake of macro- and micronutrients and with better plasmatic levels of fat-soluble vitamins.     

A Six-Month Study of Growth and Energy Expenditure in Children with Cystic Fibrosis Taking a Pulmonary Inhalation Medication (rhDNase)

Objective: To characterize the effects of recombinant human deoxyribonuclease (rhDNase) on growth velocity, body composition, resting energy expenditure (REE) and food intake in children with cystic fibrosis (CF).

Methods: A prospective, six-month pilot study was conducted in twenty-one subjects with CF (twelve male, nine female, ages 11.5±3.1 years) measured at baseline, two and six months post-baseline. Repeated measures ANOVA was used to examine the change in variables across time.

Results: The majority (75%) of subjects had minimal lung disease at baseline (FEV₁: 80%–119% predicted). As expected for growing children, weight and height gains (1.6 kg and 2.5 cm) were observed between baseline and six months (p=0.0001). No change was observed in weight z-scores from six months prior to initiation of rhDNase therapy to six months post, though a significant decline (p=0.049) in Ht z-score was observed over this twelve-month period. Triceps skinfolds and mid-arm muscle circumference increased from baseline to six months (p<0.01); respective z-scores remained stable. Energy intake remained constant during the period it was studied from baseline to two months of therapy: 120%±27% RDA. REE, though slightly elevated compared to healthy children (baseline 106%±8% predicted), remained stable throughout the study and at a level which may be expected for children with minimal lung disease. A trend (p=0.057) towards a decrease in the number of subjects requiring hospitalization for pulmonary exacerbations during the trial period was observed.

Conclusions: In summary, these pilot data from younger children with milder CF-related lung disease do not confirm anecdotal reports of improved rate of weight gain, caloric intake or decreases in the elevated REE. Future research might focus on documentation of the possible nutritional effects of rhDNase in clinical trials of children with more severe lung disease.     

Handgrip Strength: Associations with Clinical Variables,Body Composition,and Bone Mineral Density in Adults with Cystic Fibrosis

Background: Loss of fat-free mass (FFM) is associated with an increase in morbidity and mortality in cystic fibrosis (CF) patients. Handgrip strength (HGS) measures muscle function and may be associated with clinical parameters with prognostic value. Our objectives were to evaluate muscle strength through HGS in CF patients and to determine if there are any associations with respiratory clinical variables, FFM, and bone mineral density (BMD). Methods: A cross-sectional study conducted in clinically stable patients. We evaluated muscle function through HGS, respiratory function—forced expiratory volume in 1 s (FEV1) (%), forced vital capacity (FVC) (%), bronchorrhea, annual exacerbations, and body composition (FFM and FFM index, FFMI: fat-free mass in kg/height in m²) and Bone Mineral Density (BMD) through densitometry (DXA). Results: The study included 53 CF patients (58.5% females, mean age 28.3 ± 8.1, body mass index (BMI) 21.7 ± 3.4). The mean values for dynamometry were 40.2 ± 8.1 kg in males and 23.1 ± 7.0 kg in women, being 20.8% below the 10th percentile. Patients with lower muscle strength showed significantly more exacerbations and lower FEV1% and FVC%, as well as lower BMI, worse BMD (g/cm²), T-score, and Z-score. A significant and positive correlation was found between the mean and maximum dynamometry values and age, FVC%, BMI, FFMI, FFM (kg), and BMD. Conclusions: For adults with CF, HGS is a practical tool for assessment of health status. Low values reflect poor nutritional status and are associated with poor respiratory function, low fat-free mass and low bone mineral density.     

Spirituality's Role in Chronic Disease Self-Management: Sanctification of the Body in Families Dealing With Cystic Fibrosis

Sanctifying the Body (imbuing the body and its care with spiritual significance) is associated with pro-healthy behaviors and may be associated with adherence in families with chronic diseases. Our objective was to determine this construct's relevance to cystic fibrosis (CF) families and test the reliability and validity of a shortened Sanctification measure. The “Sacred Qualities of the Body” and “Manifestation of God in the Body” scales were completed by parents (N = 92) and adolescents with CF (N = 32) in a CF Clinic or by mail. Internal consistency reliability and factor analysis were performed on the parent sample. Parents and adolescents endorsed the construct. Internal consistency and validity was shown for adults and factor analysis showed two factors. Adolescent interest in an electronic spirituality chatroom correlated with increased sanctification. Sanctification is a relevant, measurable construct representing an under-appreciated aspect of the web of values contributing to adherence and health and bears further examination.     

Resting Energy Expenditure in Critically Ill Patients With Spontaneous Intracranial Hemorrhage

Background: Data on energy requirements of patients with spontaneous intracranial hemorrhage (SICH) are scarce. The objective of this study was to determine the resting energy expenditure (REE) in critically ill patients with SICH and to compare it with the predicted basal metabolic rate (BMR). Methods: In 30 nonseptic patients with SICH, the REE was measured during the 10 first posthemorrhage days with the use of indirect calorimetry (IC). Predicted BMR was also evaluated by the Harris‐Benedict (HB) equation. Bland‐Altman analysis was used to evaluate the agreement between measured and predicted values. The possible effect of confounding factors (demographics, disease, and severity of illness score) on the evolution of continuous variables was also tested. Results: mean predicted BMR, calculated by the HB equation, was 1580.3 ± 262 kcal/d, while measured REE was 1878.9 ± 478 kcal/d (117.5% BMR). Compared with BMR, measured REE values showed a statistically significant increase at all studied points (P < .005). Measured and predicted values showed a good correlation (r = 0.73, P < .001), but the test of agreement between the 2 methods with the Bland‐Altman analysis showed a mean bias (294.6 ± 265.6 kcal/d) and limits of agreement (–226 to 815.29 kcal/d) that were beyond the clinically acceptable range. REE values presented a trend toward increase over time (P = .077), reaching significance (P < .005) after the seventh day. Significant correlation was found between REE and temperature (P = .002, r = 0.63), as well as between REE and cortisol level (P = .017, r = 0.62) on the 10th day. No correlation was identified between REE and depth of sedation, as well as Acute Physiology and Chronic Health Evaluation II, Glasgow Coma Scale, and Hunt and Hess scores. Conclusions: During the early posthemorrhagic stage, energy requirements of critically ill patients with SICH are increased, presenting a trend toward increase over time. Compared with IC, the HB equation underestimates energy requirements and is inefficient in detecting individual variability of REE in this group of patients.     

Pancreatic Enzyme Replacement Therapy in Cystic Fibrosis

While typically considered a pulmonary disease, cystic fibrosis patients develop significant nutritional complications and comorbidities, especially those who are pancreatic insufficient. Clinicians must have a high suspicion for cystic fibrosis among patients with clinical symptoms of pancreatic insufficiency, and pancreatic enzymatic replacement therapy (PERT) must be urgently initiated. PERT presents a myriad of considerations for patients and their supporting dieticians and clinicians, including types of administration, therapy failures, and complications.     

Correlates of Pancreatic Enzyme Replacement Therapy Intake in Adults with Cystic Fibrosis: Results of a Cross-Sectional Study

Most people with cystic fibrosis (pwCF) develop pancreatic insufficiency and are treated with pancreatic enzyme replacement therapy (PERT). We aimed to describe the use of PERT and assess the correlates of PERT dose in adult pwCF. In a cross-sectional study at the Copenhagen CF Centre, the participants reported PERT intake, gastrointestinal (GI) symptoms and the use of concomitant treatments. Demographic and clinical characteristics were extracted from the Danish CF Registry. We used linear regression to assess the correlates of PERT dose per kg bodyweight (U-lipase/kg). We included 120 pwCF with a median age of 32.9 years, 46% women and 72% F508delta homozygote. The PERT dose ranged from 0 to 6160 U-lipase/kg per main meal (mean 1828; SD 1115). The PERT dose was associated with participants’ sex (men vs. women: 661; 95% CI: 302; 1020 U-lipase/kg), age (−16; 95% CI: −31; −1 U-lipase/kg per year) and weight (−45; 95% CI: −58; −31 U-lipase/kg per kg). Having less frequent constipation and being lung transplanted were also associated with a higher PERT dose. A third of participants did not take PERT for snacks, and this was associated with the frequency of diarrhoea. These findings indicate that PERT intake may be improved to reduce GI symptoms.     

The Experience of Receiving a Diagnosis of Cystic Fibrosis After Age 20

Abstract

Using the phenomenological approach of Van Manen, this study explored the lived experience of receiving a diagnosis of cystic fibrosis as an adult. Ten essential themes were generated from the stories of 36 participants: Awareness of Death, Change, Difference, Distraction, Family Indifference, Intrusion, Isolation, Normalizing, Time, and Uncertainty. Themes associated with gender, illness severity, and medical care were also developed. Although themes were similar to those in the chronic illness literature, late-diagnosis of CF was found to be a unique experience. Participants sought personal relationships with caregivers and educational materials targeted to their needs. Implications for social work are discussed.