Investigation of measured and predicted resting energy needs in adults after spinal cord injury: a systematic review

Abstract

Background: Accurate estimation of energy needs is vital for effective nutritional management of individuals with spinal cord injury (SCI). Inappropriate energy prescription after SCI can compound the rates of malnutrition or obesity, increase the risk of complications and negatively influence outcomes. Energy requirements following SCI are not well understood, and there is currently no universally accepted method of estimating energy needs in clinical practice. Study design: This is a systematic literature review. Objectives: The objectives of this study were to investigate and compare the measured resting energy needs of adults with SCI across different phases of rehabilitation, and to identify appropriate energy prediction equations for use in SCI. Setting: This study was conducted in Australia. Methods: MEDLINE, EMBASE and CENTRAL databases were searched for studies published between 1975 and April 2015, identifying 298 articles. Full articles in English language of adults with SCI who were fasted for a minimum of 8 hours before undergoing indirect calorimetry to measure resting energy expenditure (REE) for at least 20 min were selected. On the basis of the inclusion criteria, 18 articles remained for data extraction. One author extracted information from all articles, and inter-rater reliability was tested in five articles. Results: REE across three phases of injury was assessed: acute, sub-acute and chronic. Few studies (n = 2) have investigated REE in the acute and sub-acute injury stages of SCI recovery. The factors influencing chronic energy needs in SCI patient populations are many and varied, and a valid predictive equation for use in SCI remains elusive. SCI is initially associated with catabolic conditions of trauma such as spinal shock and patients may be at risk of weight loss, malnutrition and pressure injuries. 1 In the long term, SCI results in marked body composition changes, specifically muscle atrophy below the level of injury and higher relative fat mass compared with people without SCI, 1-3 which may contribute to decreases in resting energy expenditure (REE). In an environment of reduced mobility, energy needs are further reduced, and there is an increased risk of weight gain and obesity-related chronic diseases. 4,5 To prescribe an appropriate daily energy intake, an individual's total daily energy expenditure (TDEE) must be determined. An individual's TDEE comprises three components, two of which may be considerably affected by SCI. Basal metabolic rate (BMR) is the minimum energy required for the basal processes of life, and it contributes the majority (~70%) of TDEE in a healthy person. 6 In the clinical literature, the term BMR is often used interchangeably with REE, and for the purpose of this review REE is defined as the energy expended in an awake, alert individual in a rested position following

Feasibility and Acceptability of Implementing Indirect Calorimetry Into Routine Clinical Care of Patients With Spinal Cord Injury

“…Intra-individual variation in REE was less than 10%, which is similar to previously published data in a number of patient groups including the elderly 35,36 and young healthy free-living men. 37 In keeping with previous studies, 6 there was large variation between measured and predicted REE, further highlighting the importance of using IC to assess REE in clinical practice.…”

“…8 Energy expenditure in people with SCI is highly variable 6 and may be influenced by lean body mass, 9 injury level and completeness, 6 bone mineral density, 10 medications, 11 and common secondary complications such as urinary tract infections and pressure ulcers. 12 Delivery of targeted nutrition interventions after SCI will continue to be challenging in the absence of a reliable method to assess energy needs.…”

“…13 There remains no valid alternative method for measuring REE in clinical practice. 6 Despite this, use of IC is often confined to the research setting, I t is well established that spinal cord injury (SCI) results in dramatic changes to body composition, including significant muscle atrophy below the level of injury and increased fat mass. [1][2][3][4] As a result, predictive equations that are typically used to determine energy requirements (such as Harris-Benedict or Schofield) are not valid for use in people with SCI.…”

“…[1][2][3][4] As a result, predictive equations that are typically used to determine energy requirements (such as Harris-Benedict or Schofield) are not valid for use in people with SCI. 1,2,5 There is no reliable energy prediction equation validated for use in SCI patients, 6 and it remains unclear how best to estimate energy needs in clinical practice.…”

Contributors to Metabolic Disease Risk Following Spinal Cord Injury

“…Concomitant with these potential energy expenditure reductions, metabolic substrate utilization based on the respiratory exchange ratio (or respiratory quotient) suggest reduced carbohydrate utilization, particularly after a meal [78;79], in agreement with elevated blood glucose during this same period[80] and the observed glucose intolerance following SCI [5;6;9]. Although making up a smaller overall percentage of daily energy expenditure, diet-induced thermogenesis (or the thermic effect of feeding) and cold-induced thermogenesis have been inconsistently reported as lower in subjects with SCI, with higher level injuries having greater deficits [79;81;82]. Differences between study methodologies including the duration and type of metabolic rate measure, time since injury, standardized conditions (time of day if not whole day, composition of meals used for feeding tests, temperature monitoring of room and clothing utilized, medication usage, SNS function and anatomic level of SCI, etc.)…”