The nutritional care and management of patients includes provision of adequate nutrition support to ensure that they attain and maintain a desirable body weight, improve nutritional status and avoid negative outcomes associated with over- or underfeeding. The success of nutrition support relies on accurately estimating energy requirements so that adequate energy and nutrients can be provided to the patient. Energy requirements are most accurately determined by measurement of energy expenditure. Most methods for doing so however are expensive, time-consuming, require trained technicians to perform them and are therefore impractical in the clinical setting. As such, prediction equations, which are easy to use, inexpensive and universally available, are commonly used to estimate the energy requirements of hospitalised patients. The accuracy of these equations however is questionable. Recently, a new portable hand-held indirect calorimeter (MedGem(tm), HealtheTech, USA), which has been promoted for its ease of use and relatively short measurement time, has been validated in healthy subjects but is yet to be validated in patients with illnesses. Weight loss and malnutrition occur commonly in patients with cancer and are often thought to be associated with disturbances in energy metabolism caused by the tumour. Minimising weight loss is an important goal for the nutritional care of patients with cancer. The ability to accurately determine the energy requirements of these patients is therefore essential for the provision of optimal nutrition support. This research project proceeded in two phases. Phase 1 aimed to determine current methods used by dietitians for estimating adult patients' energy requirements using a descriptive study. Results of this study informed phase 2, which aimed to investigate differences in energy expenditure of cancer patients compared to healthy control subjects and to compare different methods for determining energy requirements of people with cancer in the clinical setting. To address phase 1 a national cross-sectional survey of dietitians working in acute care adult hospitals was undertaken to determine their usual dietetic practice with respect to estimating patients' energy requirements. Responses to the survey (n=307, 66.2%) indicated a large variation in dietitians' practice for estimating energy requirements particularly with respect to the application of methods involving injury factors. When applied to a case study, these inconsistencies resulted in an extremely wide range for the calculated energy requirement, suggesting that there is error inherent in the use of prediction methods, which may be associated with negative consequences associated with under- or overfeeding. The types of patients for whom dietitians estimate energy requirements appears to be heavily influenced by feeding method. Initial dietetic education was identified as the main influencing factor in the choice of method for estimation of energy requirements. Phase 2 was addressed using four studies based on the same study population - a case-control study, two clinical validation studies and a measurement methods study. Patients had histologically proven solid tumours, excluding tumours of the breast, prostate and brain, and were undergoing anti-cancer therapy (n=18). Healthy control subjects were group matched to cancer patients by gender, age, height and weight from a purposive sample (n=17). Resting energy expenditure (REE) was measured by respiratory gas exchange using a traditional indirect calorimeter (VMax 229) and the MedGem indirect calorimeter. A measurement methods side-study established that steady state defined as a three-minute period compared to a five-minute period measured REE within clinically acceptable limits. REE was also predicted from a range of prediction equations. Analyses of available data found that REE in cancer patients was not significantly different from healthy subjects, with only a 10% higher REE observed in this sample of cancer patients when adjusted for fat free mass. For both cancer patients and healthy subjects the portable MedGem indirect calorimeter and all prediction equations did not measure or estimate individual REE within clinically acceptable limits compared to the VMax 229 (limits of agreement of approximately -40% to 30% for both the MedGem and prediction equations). Collectively, the results of this research project have indicated that current practical methods for determining patients' energy requirements in a clinical setting do not accurately predict the resting energy expenditure of individual subjects, healthy or with cancer. Greater emphasis should therefore be placed on ensuring intake meets requirements. For this to occur, dietetic practice should be focused on directly monitoring both patients' actual energy intake and patient outcomes, such as weight, body composition and nutritional status, to determine whether energy requirements are being met. This research has led to multiple recommendations for dietetic practice, focusing on the standardisation of education practices. Recommendations for future research address methodological improvements.
| Identifer | oai:union.ndltd.org:ADTP/264949 |
| Date | January 2004 |
| Creators | Reeves, Marina Michelle |
| Publisher | Queensland University of Technology |
| Source Sets | Australiasian Digital Theses Program |
| Detected Language | English |
| Rights | Copyright Marina Michelle Reeves |
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