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American Dietetic Association Publishes Evidence-based Nutrition Practice Guidelines for Registered Dietitians

FOR RELEASE SEPTEMBER 25, 2006

Media contacts: Doris Acosta, Tom Ryan
800/877-1600 ext. 4822, 4894
dacosta@eatright.org

CHICAGO — The American Dietetic Association, the nation’s largest organization of food and nutrition professionals, has published evidence-based nutrition practice guidelines for registered dietitians on disorders of lipid metabolism, adult weight management and critical illness.

“ADA’s online Evidence Analysis Library summarizes for RDs the results of the best available research on topics in nutrition and health and offers recommendations for registered dietitians to follow in their treatment of clients and patients,” said ADA President and registered dietitian Judith A. Gilbride.

ADA’s evidence-based practice guidelines have been developed by a combination of RDs who are experts in their field and specialists trained in conducting and analyzing scientific research. The guidelines have been reviewed by multidisciplinary teams consisting of registered dietitians, doctors, pharmacists, registered nurses and professors from institutions such as Harvard Medical School, University of Pittsburgh School of Medicine, University of Texas, University of Tennessee, Oregon Health and Science University, University of Pennsylvania and University of Nebraska.

Recommendations in ADA’s guidelines, as well as grades assigned to the strength of the scientific evidence used in supporting the recommendations, should not be interpreted as endorsements by the American Dietetic Association of any brand-name product or service. Consumers who want to know more about nutrition and health are encouraged to consult with a registered dietitian in their area.

Registered dietitians will find recommendations that describe the use of trans-fatty acids, stanols and sterols and antioxidants in order to aid in the treatment of lipid metabolism disorders. The disorders of lipid metabolism guideline also states, if consistent with patient preference and not contraindicated by risks or harms, omega-3 fatty acids, preferably from both marine and plant sources, should be included in a cardioprotective diet.

Consuming dietary sources of omega-3 fatty acids from fish [two 4oz servings of fish per week (preferably fatty fish such as mackerel, salmon, herring, trout, sardines or tuna)] and plant-based foods of 1.5g alpha-linolenic acids (1 Tbs canola or walnut oil, 0.5 Tbs ground flax seed, <1 tsp flaxseed oil) are recommended. Consumption of increased omega-3 fatty acids is associated with a decreased risk of death from cardiac events and non-fatal MIs. Some fatty fish can be high in methylmercury and should be limited, according to the FDA. If an individual does not eat food sources of omega-3 fatty acids, then 1g of EPA and DHA omega-3 fatty acid supplements may be recommended for secondary prevention.

To assist registered dietitians in their assessment and treatment of excess weight and obesity, ADA’s adult weight management guideline covers everything from the ideal duration of a weight management program to low-glycemic index diets, weight loss medications to bariatric surgery. The adult weight management guideline also states, for people who have difficulty with self selection and/or portion control, meal replacements may be used as part of the diet component of a comprehensive weight management program.

A low glycemic index diet is not recommended for weight loss or weight maintenance as part of a comprehensive weight management program, since it has not been shown to be effective in these areas. Having patients focus on reducing carbohydrates rather than reducing calories and/or fat may be a short term strategy for some individuals. Research indicates that focusing on reducing carbohydrate intake (<35% of kcals from carbohydrates) results in reduced energy intake. Consumption of a low-carbohydrate diet is associated with a greater weight and fat loss than traditional reduced calorie diets during the first 6 months, but these differences are not significant after one year.

Those who are treating the critically ill, have numerous recommendations aimed at properly nourishing this high-risk group, reducing infectious complications and shortening the length of time in the ICU. More detailed information on ADA’s disorders of lipid metabolism, weight management and critical illness guidelines is attached in the executive summary.

Every EAL recommendation is assigned a rating based on grades of evidence assigned to represent the strength and reliability of the scientific studies that have been conducted to support it. Grades are not intended to compare or rank any particular approach over another. For example, a “Strong” recommendation indicates that the” benefits of the recommended approach clearly exceed the harms … and that the quality of the supporting evidence is excellent.” On the other hand, “Weak” means “the quality of evidence that exists is suspect or that well-done studies … show little clear advantage to one approach versus another.”

Recommendations can be worded as conditional or imperative statements. Conditional statements clearly define a specific situation, while imperative statements are broadly applicable to the target population without restraints on their pertinence. In some cases, recommendations are rated “Consensus,” meaning “expert opinion supports the guideline recommendation even though the available scientific evidence did not present consistent results or controlled trials were lacking.” And “Insufficient Evidence” means there is “both a lack of pertinent evidence and/or an unclear balance between benefits and harms.”

Below are executive summaries of the major recommendations and ratings for the Disorders of Lipid Metabolism Guideline, Adult Weight Management Guideline and Critical Illness Guideline.

With approximately 65,000 members, the American Dietetic Association is the nation’s largest organization of food and nutrition professionals. ADA serves the public by promoting optimal nutrition, health and well-being. To locate a registered dietitian in your area, visit ADA at www.eatright.org.

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EXECUTIVE SUMMARY: DISORDERS OF LIPID METABOLISM GUIDELINE
Below are the major recommendations and ratings for the Disorders of Lipid Metabolism Evidence-Based Nutrition Practice Guideline.

Medical Nutrition Therapy
Referral to a Registered Dietitian for Medical Nutrition Therapy (MNT) and Disorders of Lipid Metabolism
Referral to a registered dietitian for Medical Nutrition Therapy (MNT) is recommended whenever an individual has an abnormal lipid profile, based on ATPIII Risk category and LDL-C goals or has CHD. A planned initial visit lasting from 45-90 minutes and at least two to six planned follow-up visits (30-60 minutes each, with an RD) can lead to improved dietary pattern; improved lipid profile; reduced plasma total cholesterol, LDL-C and triglycerides; and improved weight status. Strong, Conditional

The number and duration of visits in the course of Medical Nutrition Therapy will need to be greater if the client is in a higher risk category, if there is a large number of Therapeutic Lifestyle Changes (TLC) that need to be made and if the individual is not motivated to make TLC changes. Increasing the number of visits and length of time spent with a dietitian can improve serum lipid levels and CVD risk. Fair, Conditional

Re-evaluate the dosage and necessity of lipid-lowering medications throughout the course of Medical Nutrition Therapy. Medical Nutrition Therapy may successfully improve the lipid levels to the point where medication doses can be lowered or discontinued. Fair, Imperative

Energy Balance
Body Mass Index, Waist Circumference or Waist-to-Hip Ratio (WHR) and Disorders of Lipid Metabolism

In addition to BMI, use waist circumference or WHR to assess obesity and CVD risk. BMI alone is not a good predictor of CVD risk in persons over 65 years old. Increases in waist circumference, WHR and BMI are associated with CHD events and CVD mortality. Strong, Imperative

Macronutrients: Fat
Major Dietary Fat Components and Lipid Metabolism Disorders
The cardioprotective dietary pattern should be tailored to the individual's needs to provide a fat intake of 25-35% of calories, <7% of calories from saturated fat and trans-fatty acids and <200 mg cholesterol per day. This dietary pattern can lower LDL-cholesterol up to 16% and decrease risk of CHD. Strong, Imperative

The cardioprotective dietary pattern should be as low as possible in saturated and trans fatty acids and less than 7% of calories. For individuals at their appropriate body weight without elevated LDL-cholesterol or triglyceride levels and with normal HDL-cholesterol levels, saturated fatty acid calories could be replaced by unsaturated fat and/or complex carbohydrate. Replacing saturated fats with mono- and polyunsaturated fat lowers LDL-cholesterol, without lowering HDL-cholesterol or increasing triglycerides, although the ideal replacement percentages are unclear. Research is needed on how best to titrate these recommendations. Strong, Imperative

Trans-Fatty Acid Intake and Disorders of Lipid Metabolism
Trans-fatty acids consumption should be as low as possible. A cardioprotective dietary pattern should contain less than 7% of calories from saturated fat and trans-fatty acids. Trans-fatty acids raise total cholesterol and LDL-C and may decrease HDL-C, thereby increasing the TC/HDL-C and LDL-C/HDL-C ratios. Increasing trans-fatty acid intake increases risk of CHD events. Strong, Imperative

Omega-3 Fatty Acids and Disorders of Lipid Metabolism
If consistent with patient preference and not contraindicated by risks or harms, omega-3 fatty acids, preferably from both marine and plant sources, should be included in a cardioprotective diet. Consuming dietary sources of omega-3 fatty acids from fish [two 4oz servings of fish per week (preferably fatty fish such as mackerel, salmon, herring, trout, sardines or tuna)] and plant-based foods of 1.5g alpha-linolenic acids (1 Tbs canola or walnut oil, 0.5 Tbs ground flax seed, <1 tsp flaxseed oil) are recommended. Consumption of increased omega-3 fatty acids is associated with a decreased risk of death from cardiac events and non-fatal MIs. Some fatty fish can be high in methylmercury and should be limited, according to the FDA. Fair, Conditional

If an individual does not eat food sources of omega-3 fatty acids, then 1g of EPA and DHA omega-3 fatty acid supplements may be recommended for secondary prevention. Fair, Conditional

Macronutrients
Carbohydrates and Protein, Including Dietary Fiber and Disorders of Lipid Metabolism
The cardioprotective dietary pattern should be as low as possible in saturated and trans fatty acids and less than 7% of calories. Saturated fatty acid and trans-fatty acid calories may be replaced by unsaturated fatty acids, complex carbohydrates and protein. However, studies to determine the ideal percentages of these macronutrients as replacements for saturated fat are needed. Strong, Imperative

Include foods containing 25-30 grams of fiber per day, with special emphasis on soluble fiber sources (7-13 grams), as part of a cardioprotective diet. Foods rich in soluble fiber include: fruits, vegetables and whole grains, especially high-fiber cereals, oatmeal, beans and prunes. Risk factors associated with CHD (blood pressure, lipoprotein subclasses and particle sizes, insulin resistance and post-prandial glucose) and CVD (fatal and non-fatal MI and stroke) are decreased as dietary fiber intake increases. Diets high in total and soluble fiber, as part of a cardioprotective diet, can further reduce TC by 2-3% and LDL up to 7%. Strong, Imperative

Specific Foods
Plant Stanols and Sterols and Disorders of Lipid Metabolism
If consistent with patient preference and not contraindicated by risks or harms, then plant sterol and stanol ester enriched foods consumed two or three times per day, for a total consumption of two or three grams per day, may be used in addition to a cardioprotective diet to further lower TC by 4-11% and LDL-C by 7-15%. For maximal effectiveness, foods containing plant sterols and stanols (spreads, juices, yogurts) should be eaten with other foods. To prevent weight gain, isocalorically substitute stanol- and sterol-enriched foods for other foods. Plant stanols and sterols are effective in people taking statin drugs. Strong, Conditional

Soy Protein and Disorders of Lipid Metabolism
If consistent with patient preference and not contraindicated by risks/harms, then soy (e.g., isolated soy protein, textured soy, tofu) may be included as part of a cardioprotective diet. Consuming 26-50g of soy protein per day in place of animal protein can reduce TC by 0-20% and LDL-C by 4-24%. Evidence is insufficient to establish a beneficial role of isoflavones as an independent component. Fair, Conditional

Nuts, Disorders of Lipid Metabolism and CHD
If consistent with patient preference and not contraindicated by risks or harms, then nuts (walnuts, almonds, peanuts, macadamia, pistachios and pecans) may be isocalorically incorporated into a cardioprotective dietary pattern. Consuming five ounces of nuts per week is associated with a reduced risk of CHD. Because of their beneficial fatty acid profile as well as other nutritional components, nuts may be incorporated into a cardioprotective dietary pattern low in saturated fat and cholesterol to reduce TC by 4-21% and LDL-C by 6-29%. Fair, Conditional

Alcohol Intake and Disorders of Lipid Metabolism
Current evidence does not justify encouraging those who do not drink alcohol to start doing so. If a patient currently drinks alcohol and if not contraindicated, then a maximum of one drink per day for women and up to two drinks per day for men may be incorporated into a cardioprotective dietary pattern with meals within recommended calorie levels. This level of alcohol consumption has been demonstrated to be associated with a reduced risk of CVD. There is no evidence that one type of alcohol is better than another. Fair, Conditional

Micronutrients
Antioxidants (Vitamin E, Vitamin C and Beta-Carotene), Disorders of Lipid Metabolism and CHD
Antioxidants such as vitamin E, vitamin C and B-carotene (or carotenoids) should be specifically planned into a cardioprotective dietary pattern. Antioxidant-rich fruits, vegetables and whole grains have been shown to be associated with reduced disease risk. Fair, Imperative

Vitamin E, vitamin C and B-carotene supplements should not be recommended to reduce the risk of CVD. These supplements have shown no protection for CVD events or mortality. Strong, Imperative

Supplemental vitamin E, vitamin C, B-carotene and selenium should not be taken with a Simvastatin/Niacin drug combination. Supplemental B-carotene cannot be recommended in individuals with a smoking habit. Research indicates that in these situations there is an increased risk. Fair, Imperative

Homocysteine, Folate or Vitamin B6 or B12 and Prevention of CHD
Folate, vitamin B6 and vitamin B12 should be planned into the cardioprotective dietary pattern to meet the DRI. If an individual has high serum homocysteine levels (usually greater than 13 umol/L), these B vitamins may lower serum homocysteine levels by 17-34%. Fair, Imperative

Supplemental folate, given alone or in combination with B6 and B12 may or may not be beneficial. If a patient with CVD is taking supplemental B vitamins to lower homocysteine, then dietetics professionals may decide to discuss the evidence for supplemental B vitamin and CVD events. Research has shown that after six months to two years, supplemental folate and B-vitamins did not reduce the risk for coronary events. Consultation with the patient's physician is warranted. Weak, Conditional

Coenzyme Q10 and Disorders of Lipid Metabolism
If a patient is taking coenzyme Q10 supplements, then the practitioner may discuss the lack of evidence for the association of Q10 and CHD events. Research is inconclusive regarding the relationship between co-Q10 and risk of disease. Insufficient Evidence, Conditional

Behavior/Physical Activity
Physical Activity and Lipid Metabolism Disorders and CHD
Moderate intensity physical activity (e.g., brisk walking, swimming laps, bicycling) should be incorporated for at least 30 minutes most, if not all, days of the week, if not contraindicated. Many individuals will have to start slowly and increase gradually to achieve goals. Moderately intense physical activity reduces the risk of CVD events, decreases LDL-C and triglycerides and increases HDL-C. Strong, Imperative

Corollary Health Issues
Disorders of Lipid Metabolism and Hypertension
A cardioprotective dietary pattern should be planned to include 9-12 servings of fruits and vegetables, 2-3 servings of low-fat dairy products, <2.3g sodium, lose weight if necessary and increase physical activity (moderate intensity 3 times per week) if individuals also need to lower their blood pressure. Following this type of lifestyle change has been demonstrated to lower systolic blood pressure by at least 4-12 mmHg. Strong, Imperative

Disorders of Lipid Metabolism and Metabolic Syndrome
A calorie-controlled cardioprotective dietary pattern that avoids extremes in carbohydrate and fat intake, limits refined sugar and includes physical activity at a moderate-intensity level for at least 30 minutes on most (preferably all) days of the week, should be used for individuals with metabolic syndrome. Weight loss of 7-10% of body weight should be encouraged if indicated. These lifestyle changes improve risk factors of metabolic syndrome. Fair, Imperative

EXECUTIVE SUMMARY: ADULT WEIGHT MANAGEMENT GUIDELINE
Nutrition Assessment and Treatment
Practice recommendations for registered dietitians in 15 areas ranging from goal setting and meal replacements to portion control and bariatric surgery.

Classification of Overweight and Obesity
Body mass index (BMI) and waist circumference should be used to classify overweight and obesity, estimate risk for disease and to identify treatment options. BMI and waist circumference are highly correlated to obesity or fat mass and risk of other diseases (NHLBI report). Fair, Imperative

Body weight and waist circumference should be used to determine the effectiveness of therapy in the reassessment. BMI and waist circumference are highly correlated to obesity or fat mass (NHLBI report). Fair, Imperative

Comprehensive Weight Management Program
Weight loss and weight maintenance therapy should be based on a comprehensive weight management program including diet, physical activity and behavior therapy. The combination therapy is more successful than using any one intervention alone. Strong, Imperative

Optimal Length of Weight Management Therapy
Medical Nutrition Therapy for weight loss should last at least 6 months or until weight loss goals are achieved, with implementation of a weight maintenance program after that time. A greater frequency of contacts between the patient and practitioner may lead to more successful weight loss and maintenance. Strong, Imperative

Realistic Weight Goal Setting
Individualized goals of weight loss therapy should be to reduce body weight at an optimal rate of 1-2 lbs per week for the first 6 months and to achieve an initial weight loss goal of up to 10% from baseline. These goals are realistic, achievable and sustainable. Strong, Imperative

Determination of Resting Metabolic Rate
Estimated energy needs should be based on RMR. If possible, RMR should be measured (e.g., indirect calorimetry). If RMR cannot be measured, then the Mifflin-St. Jeor equation using actual weight is the most accurate for estimating RMR for overweight and obese individuals. Strong, Conditional

Dietary Interventions
Reduced Calorie Diets
An individualized reduced calorie diet is the basis of the dietary component of a comprehensive weight management program. Reducing dietary fat and/or carbohydrates is a practical way to create a caloric deficit of 500 – 1000 kcals below estimated energy needs and should result in a weight loss of 1 – 2 lbs per week. Strong, Imperative

Eating Frequency and Patterns
Total caloric intake should be distributed throughout the day, with the consumption of 4 to 5 meals/snacks per day including breakfast. Consumption of greater energy intake during the day may be preferable to evening consumption. Fair, Imperative

Portion Control
Portion control should be included as part of a comprehensive weight management program. Portion control at meals and snacks results in reduced energy intake and weight loss. Fair, Imperative

Meal Replacements
For people who have difficulty with self selection and/or portion control, meal replacements (e.g., liquid meals, meal bars, calorie-controlled packaged meals) may be used as part of the diet component of a comprehensive weight management program. Substituting one or two daily meals or snacks with meal replacements is a successful weight loss and weight maintenance strategy. Strong, Conditional

Nutrition Education
Nutrition education should be individualized and included as part of the diet component of a comprehensive weight management program. Short term studies show that nutrition education (e.g. reading nutrition labels, recipe modification, cooking classes) increases knowledge and may lead to improved food choices. Fair, Imperative

Selected Dietary Approaches
The work group examined the existing literature on some specific diets based on the availability of research as well as interest.

Low Glycemic Index Diets
A low glycemic index diet is not recommended for weight loss or weight maintenance as part of a comprehensive weight management program, since it has not been shown to be effective in these areas. Strong, Imperative

Dairy/Calcium and Weight Management
In order to meet current nutritional recommendations, incorporate 3-4 servings of low fat dairy foods a day as part of the diet component of a comprehensive weight management program. Research suggests that calcium intake lower than recommended levels is associated with increased body weight. However, the effect of dairy and/or calcium at or above recommended levels on weight management is unclear. Fair, Imperative

Low Carbohydrate Diet
Having patients focus on reducing carbohydrates rather than reducing calories and/or fat may be a short term strategy for some individuals. Research indicates that focusing on reducing carbohydrate intake (<35% of kcals from carbohydrates) results in reduced energy intake. Consumption of a low-carbohydrate diet is associated with a greater weight and fat loss than traditional reduced calorie diets during the first 6 months, but these differences are not significant after one year. Fair, Conditional

Physical Activity Interventions
Physical Activity
Physical activity should be part of a comprehensive weight management program. Physical activity level should be assessed and individualized long-term goals established to accumulate at least 30 minutes or more of moderate intensity physical activity on most and preferably, all days of the week, unless medically contraindicated. Physical activity contributes to weight loss, may decrease abdominal fat and may help with maintenance of weight loss. Strong, Imperative

Behavioral Interventions
Multiple Behavior Therapy Strategies
A comprehensive weight management program should make maximum use of multiple strategies for behavior therapy (e.g. self monitoring, stress management, stimulus control, problem solving, contingency management, cognitive restructuring and social support). Behavior therapy in addition to diet and physical activity leads to additional weight loss. Continued behavioral interventions may be necessary to prevent a return to baseline weight. Strong, Imperative

FDA-Approved Medications for Weight Loss
Medication as Part of a Comprehensive Program
FDA-approved weight loss medications may be part of a comprehensive weight management program. Dietitians should collaborate with other members of the health care team regarding the use of FDA-approved weight loss medications for people who meet the NHLBI criteria. Research indicates that pharmacotherapy may enhance weight loss in some overweight and obese adults. Strong, Imperative

Bariatric Surgery
Bariatric Surgery for Weight Loss
Dietitians should collaborate with other members of the health care team regarding the appropriateness of bariatric surgery for people who have not achieved weight loss goals with less invasive weight loss methods and who meet the NHLBI criteria. Separate ADA evidence based guidelines are being developed on nutrition care in bariatric surgery. Strong, Imperative

EXECUTIVE SUMMARY: CRITICAL ILLNESS EVIDENCE-BASED NUTRITION PRACTICE GUIDELINE
Below are the major recommendations and ratings for the Critical Illness Evidence-Based Nutrition Practice Guideline. Click here to view the Guideline Overview. More detail (including the evidence analysis supporting these recommendations) is available to ADA members and subscribers under Major Recommendations.

Enteral versus Parenteral Nutrition
Enteral versus Parenteral Nutrition and Critical Illness
If the critically ill ICU patient is hemodynamically stable with a functional GI tract, then EN is recommended over PN. Patients who received EN experienced less septic morbidity and fewer infectious complications than patients who received PN. In the critically ill patient, EN is associated with significant cost savings when compared to PN. There is insufficient evidence to draw conclusions about the impact of EN or PN on LOS and mortality. Strong, Conditional

Timing of Feeding
Timing of Enteral Nutrition and Critical Illness
If the critically ill patient is adequately fluid resuscitated, then EN should be started within 24-48 hours following injury or admission to the ICU. Early EN is associated with a reduction in infectious complications and may reduce LOS. The impact of timing of EN on mortality has not been adequately evaluated. Strong, Conditional

Immune-Enhancing Enteral Formula
Immune-Enhancing Enteral Nutrition and Critical Illness
Immune-enhancing EN is not recommended for routine use in critically ill patients in the ICU. Immune-enhancing EN is not associated with reduced infectious complications, LOS, reduced cost of medical care, days on mechanical ventilation or mortality in moderately to less severely ill ICU patients. Their use may be associated with increased mortality in severely ill ICU patients, although adequately powered trials evaluating this have not been conducted. For the trauma patient, it is not recommended to routinely use immune-enhancing EN as its use is not associated with reduced mortality, reduced LOS, reduced infectious complications or fewer days on mechanical ventilation. Fair, Imperative

Feeding Tube Site
Gastric versus Small Bowel Feeding Tube Placement
Enteral Nutrition (EN) administered into the stomach is acceptable for most critically ill patients. Consider placing feeding tube in the small bowel when patient is in supine position or under heavy sedation. If your institution's policy is to measure GRV, then consider small bowel tube feeding placement in patients who have more than 250 mL GRV or formula reflux in two consecutive measures. Small bowel tube placement is associated with reduced GRV. Adequately powered studies have not been conducted to evaluate the impact of GRV on aspiration pneumonia. There may be specific disease states or conditions that may warrant small bowel tube placement (e.g., fistulas, pancreatitis, gastroporesis), however, they were not evaluated at this phase of the analysis. Fair, Conditional

Blue Dye Use
Blue Dye Use and Critical Illness
Blue dye should not be added to EN for detection of aspiration in critically ill patients. The risk of using blue dye outweighs any perceived benefit. The presence of blue dye in tracheal secretions is not a sensitive indicator for aspiration. Strong, Imperative

Monitoring Criteria in Critical Care
Monitoring Criteria in Critical Care
Evaluating patient position should be part of an EN monitoring plan. To decrease the incidence of aspiration pneumonia and reflux of gastric contents into the esophagus and pharnyx, critically ill patients should be placed in a 45 degree head of bed elevation, if not contraindicated. Strong, Imperative

Evaluating GRV in critically ill patients is an optional part of a monitoring plan to assess tolerance of EN. Enteral nutrition should be held when a GRV greater than or equal to 250 mL is documented on two or more consecutive occasions. Holding EN when GRV is less than 250 mL is associated with delivery of less EN. Gastric residual volume may not be a useful tool to assess the risk of aspiration pneumonia. Adequately powered studies have not been conducted to evaluate the impact of GRV on aspiration pneumonia. Consensus, Imperative

If the patient exhibits a history of gastroparesis or repeated high GRVs, then consider the use of a promotility agent in critically ill ICU patients, if there are no contraindications. The use of a promotility agent (e.g., Metoclopramide) has been associated with increased GI transit, improved feeding tolerance, improved EN delivery and possibly reduced risk of aspiration. Strong, Conditional

Monitoring Delivery of Energy
Monitoring Delivery of Energy in Critical Illness
Monitoring plan of critically ill patients must include a determination of daily actual EN intake. Enteral nutrition should be initiated within 48 hours of injury or admission and average intake actually delivered within the first week should be at least 60-70% of total estimated energy requirements as determined in the assessment. Provision of EN within this time frame and at this level may be associated with a decreased LOS, days on the mechanical ventilation and infectious complications. Fair, Imperative

Blood Glucose Control
Blood Glucose Control - Critical Illness
Evidence indicates that blood glucose < 140 mg/dL is associated with decreased mortality, LOS and infectious complications in ICU patients. Dietitians should promote attainment of these levels for BG control. Strong, Imperative

Dietitians should promote attainment of strict glycemic control (80-110 mg/dL) to reduce time on mechanical ventilation in medical ICU patients. Strong, Imperative

Energy Expenditure
Equipment
Gas Collection Devices
Use rigorous adherence to manufacturer's equipment guidelines to prevent air leaks. Air leaks will result in RMR measurement errors. Weak, Imperative

Further studies comparing modern gas collection devices (including rigid canopies, facemasks, tubing connections, sampling lines and mouthpieces with nose clips) are needed in clinical populations. Inaccurate gas collection will result in an inaccurate measurement. Insufficient Evidence, Imperative

Patient Condition
Impact of Thermic Effect of Feeding on Resting Metabolic Rate
If a critically ill patient is continuously receiving any energy source (e.g., intravenous fluids, EN or PN), the rate and concentration should remain unchanged during the 24-hour period before and during RMR measure. After 24-hour equilibration, the impact of the TEF on RMR is constant and indirect calorimetry measurements can proceed. Fair, Conditional

If a critically ill patient receives intermittent EN > 400 kcals per feeding, then hold feedings for a minimum of five hours before measuring RMR. When a five-hour fast is not clinically feasible or when a small feeding (< 400 kcals) is given, a four-hour fast is allowed. Measuring RMR during the time of the TEF will produce inaccurately high values. Weak, Conditional

Effects of Different Length Rest Periods on Resting Metabolic Rate

Allow a rest of 30 minutes prior to RMR measurement in critically ill patients. Consensus, Imperative

If the critically ill patient has undergone a nursing activity or medical procedure (e.g., suctioning, wound care, central venous access or ventilator setting change), then employ a 30-minute rest after procedures to achieve a resting state during RMR measurement. Measuring RMR before the 30-minute period may be inaccurate due to patient instability or ventilator gas re-equilibration. Consensus, Conditional

Environment
Impact of Environmental Factors on Resting Metabolic Rate Measurement: Noise, Lighting and Temperature - Critical Illness
Ensure that the room is comfortably quiet and the light is not providing heat or discomfort for the patient. Noise and light may cause erroneous measures of RMR if the critically ill patient's state of rest is disturbed. Consensus, Imperative

Recommend a room temperature 20-25 degrees Celsius (68-77 degrees Fahrenheit). When the room temperature is too cold, RMR is overestimated in critically ill patients by shivering or non-shivering thermogenesis, as the body adapts. Weak, Imperative

Impact of Environmental Factors on Resting Metabolic Rate Measurement: Physical Comfort/Posture

Ensure that each critically ill patient is in a physically comfortable posture before proceeding with the test, because discomfort will result in erroneously high RMR measures. Make sure that repeated measures are taken in the same position to ensure comparability of data. Insufficient Evidence, Imperative

Test Interpretation
Steady State Measurement Conditions and Number of Measurements in a 24-Hour Period - Critical Illness
For ventilated patients, if a steady state is achieved, then a single measure is adequate to describe RMR. To achieve a steady state, discard the first five minutes of measurement. Then achieve a five-minute period with CV =5% for oxygen consumption and carbon dioxide production. An alternate protocol can be 25 minutes in duration if a CV of =10% is achieved. If proper attention is given to achieving resting conditions, 80% or more of RMR measures in ventilator patients will be in steady state. Sedation improves the likelihood of obtaining steady state measures. Strong, Imperative

There are published data that were not in steady state, but were still reasonably close to steady state measures. When steady state is not achieved, interpret the results carefully. If the non-steady state conditions are chronic (e.g., patient posturing) then higher measures may reflect actual energy expenditure. If non-steady state conditions are episodic (e.g., ventilator change, nursing intervention, anxiety, coughing, sneezing, movement), RMR measures should be taken at a separate time. Consensus, Conditional

Respiratory Quotient as a Method to Detect Measurement Error
If RQ is < 0.7 or > 1.0, then repeated measures are necessary under more optimal conditions. An RQ <0.70 suggests hypoventilation (inadequate removal of metabolic carbon dioxide from the blood to the lung) or prolonged fasting. An RQ > 1.0 in the absence of overfeeding suggests hyperventilation (removal of carbon dioxide from the blood to the lung in excess of the amount produced by metabolism) or inaccurate gas collection. Strong, Conditional

Energy Assessment
Determination of Resting Metabolic Rate
Indirect calorimetry is the standard for determination of RMR in critically ill patients, since RMR based on measurement is more accurate than estimation using predictive equations. Strong, Imperative

If predictive equations are needed in critically ill patients, consider using one of the following, as they have the best prediction accuracy of equations studied: Ireton-Jones 1992, Penn State 2003a or Swinamer. In some individuals, errors between predicted and actual energy needs will result in under- or over-feeding. Fair, Conditional

The Harris-Benedict (with or without activity and stress factors), the Ireton-Jones 1997 and the Fick equation should not be considered for use in RMR determination in critically ill patients, as these equations do not have adequate prediction accuracy. In addition, the Mifflin-St. Jeor equation should not be considered for use in critically ill patients, as it was developed for healthy people and has not been well researched in the critically ill population. Strong, Imperative

If predictive equations are needed for critically ill, mechanically ventilated individuals with obesity, consider using Ireton-Jones 1992 or Penn State 1998, as they have the best prediction accuracy of equations studied. In some individuals, errors between predicted and actual energy needs will result in under- or over-feeding. Fair, Conditional

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