Nutrition & Dietetics 2007; 64: 192–199 DOI: 10.1111/j.1747-0080.2007.00124.

REVIEW

Back to basics: Estimating energy requirements for

adult hospital patients
Suzie FERRIE1 and Meagan WARD2
1
Royal Prince Alfred Hospital, Sydney, New South Wales, and 2Department of Nutrition and Dietetics, Austin
Health, Melbourne, Victoria, Australia

Abstract
Predictive equations are a quick and non-invasive way to estimate a patient’s energy requirements, and can be a
useful tool when used appropriately. However, as with any tool, the skill and experience of the user will affect the
quality of the result. This paper looks at the origins and limitations of some of the more commonly used equations.
Considerations in their use and interpretation, such as the use of injury and activity factors, adjusting weight and
non-protein calories, are also discussed.

Key words: basal metabolism, energy metabolism, nutrition assessment, nutrition support.

INTRODUCTION the energy expended in physical activity, and the thermic

The estimation of a patient’s requirements is an essential
component of nutrition support, ensuring that the patient’s
nutritional needs are met without significant over- or under-
feeding. In everyday hospital practice, several different equa-
tions are used, often without an adequate understanding of
their origins and limitations.1,2 This can lead to significant
variation in energy provision, which could have serious
implications for patient care. A previous review of prediction
equations concluded that none is sufficiently accurate to be
useful in practice.3 However, the reality is that equations are
the most widely used method for assessing nutrition support
that patients need in hospital. When used appropriately, a
predictive equation can be a useful tool. Although it is not a
‘magic formula’ to tell us the answer, it enables us to make
a good prediction as a starting point for ongoing patient care.
Like any tool, the equation is only as good as the person
using it: skill and experience will significantly inform the use
and interpretation of these prediction equations.
BASIC CONCEPTS
The body’s energy expenditure is usually described as con-
sisting of three components: the basal metabolic rate (BMR),
S. Ferrie, M.Nutr.Diet, APD, Critical Care Dietitian
M. Ward, M.Nutr.Diet, APD, Senior Dietitian
Correspondence: S. Ferrie, Department of Nutrition and Dietetics,
Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW
2050, Australia. Email: suzie.ferrie@cs.nsw.gov.au
Accepted September 2006
effect of feeding (TEF). The BMR is the minimum amount of
energy required to sustain the body’s essential metabolic
processes. It is the value for metabolic rate that would be
obtained when the subject first awakes (remaining relaxed,
and motionless) after an overnight fast, in a thermoneutral
setting. Resting metabolic rate (RMR) approximates the BMR
when it is not possible to meet all of the above conditions. It
is usually measured in a subject who has fasted and has been
lying quietly for at least 30 minutes before measurement.4
The TEF is the amount of energy consumed by the body after
eating, in digesting and absorbing the nutrients from food and
converting them for use or storage. It can be measured using
indirect calorimetry, by comparing the BMR with energy
expenditure measured (in the same conditions) after a meal.
TEF is usually assumed to be about 10–15% of the BMR, but
is affected by a wide range of factors, such as the subject’s
nutritional status and the composition of the diet. Other
terms used for the TEF include: ‘diet-induced thermogenesis’,
‘postprandial thermogenesis’, and ‘thermic effect of a meal’.5
The total energy expenditure is the total of basal energy
expenditure (BMR), the TEF and activity. Increased activity
raises the total, as does increased food intake (by increasing
TEF) and illness/inflammation (by increasing BMR).
The rate of energy consumption in the body changes from
moment to moment, and varies between different body
organs and tissues, but an individual’s BMR changes very
little, even over significant periods of time.6,7 Metabolic rate
measurements produce a ‘snapshot’ of energy expenditure
over a short period, which is then used to estimate the
average rate of energy expenditure for the whole day.
However, the measurement period may not reflect the true

192 © 2007 The Authors

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energy expenditure, as there is necessarily some variation
and error involved. Similarly, the energy released from food
will not provide exactly the calculated amount, because of
losses as unabsorbed nutrient, losses due to energy conver-
sion inefficiencies, and losses as heat. Decreased activity and
muscle mass with ageing, and smaller muscle mass in
women, generally contribute to a lower energy expenditure;
however, variation between individuals is significant. A
group of people of the same age and sex who have similar
body weight and body composition will not have identical
BMRs; even when intake and activity are controlled, the
variation in BMRs between different members of the group
will be as much as 10%.8
EQUATIONS FOR ESTIMATING
ENERGY REQUIREMENTS
Clearly, it would be best if it were possible to measure actual
energy expenditure, rather than just estimating it. For this
reason, indirect calorimetry is considered to be the ‘gold
standard’ for assessing energy expenditure in hospitalised
patients. This uses respiratory gas exchange to estimate fuel
consumption, and can produce accurate results when imple-
mented correctly by trained personnel. It is not infallible,
however, as its results are affected by factors such as oxygen
therapy, haemodynamic instability, fever, nursing care activi-
ties and difficulties obtaining a steady state.9 It is time-
intensive and requires expensive equipment, and at present,
most dietitians do not have access to this method for every-
day estimation of their patients’ needs.
Other measurement methods are generally not useful for
hospital patients. Direct calorimetry is not in wide use even
for research purposes, as it measures energy expenditure by
monitoring the body’s heat production and requires a spe-
cially designed sealed room with tightly controlled condi-
tions. The doubly labelled water technique is the only
research method that allows energy expenditure to be esti-
mated in free-living subjects. This uses orally administered
‘heavy’ water (containing stable isotopes of hydrogen and
oxygen) to measure the body’s carbon dioxide production as
indicated by the gradual loss of the isotopes from the body
over 1–3 weeks.4 The energy expenditure can then be esti-
mated in a similar way to that in indirect calorimetry. The
time frame for doubly labelled water studies is too long for
the assessment of most hospital patients, and the heavy
water is expensive. As an alternative to these measurement
methods, predictive equations provide a cheap, quick and
non-invasive method for estimating requirements, based on
the main factors that affect energy expenditure: age and sex
(which both affect body composition), and body size.
Researchers developing predictive equations have
attempted to validate these against measurements of energy
expenditure, often using statistical regression or correlation.
When assessing the literature, it should be noted that corre-
lation does not necessarily indicate how closely the equation
can estimate the patient’s expenditure. For example, if an
equation always produced a result that was exactly double the
true energy expenditure, it would lead to dangerous over-
© 2007 The Authors
Journal compilation © 2007 Dietitians Association of Australia
Back to basics: estimating energy requirements
Table 1 Schofield equation for estimating basal metabolic
rate (kJ/day)11,12
Age (years) Men Women
10–17 74 W + 2754 56 W + 2898
18–29 63 W + 2896 62 W + 2036
30–59 48 W + 3653 34 W + 3538
Original equations 49 W + 2459 38 W + 2755
over 60
Modified equations 49.9 W + 2930 38.6 W + 2875
60–74
Modified equations 35 W + 3434 41 W + 2610
over 75
W = weight (kg).
feeding if it was used for predicting patients’ requirements.
Statistically, though, it is considered a perfect correlation,
with a correlation coefficient r = 1. The correlation therefore
does not indicate how useful the equation would be in
practice. Validation of predictive equations should always
consider residuals, limits of agreement, or other indication of
fit, rather than just the correlation coefficient.10
Various equations have been developed for the estimation
of energy requirements, but the most commonly used equa-
tions are the Harris–Benedict equation and the Schofield
equation. More recently developed equations have attracted
attention; these include the Mifflin–St Jeor equation and the
Ireton–Jones equation.
Schofield equation11,12
The Schofield equations are an extension of the FAO/WHO/
UNU work on energy requirements13 and, as a result, are
sometimes referred to, incorrectly, as the WHO equation.14
Having since been revised by Schofield, the equation now in
use is slightly different due to the incorporation of some
extra data. It is the most commonly used by Australian
dietitians1 and has been preferred, because it does not
require a value for height and, therefore, introduces fewer
sources of error if no measured height or weight are avail-
able. Schofield did develop an additional equation that
included height, but it did not significantly increase the
accuracy of the prediction when compared with the simpler
equation. The Schofield equation (Table 1) estimates basal
requirement. It is based on a very large data set (pooled BMR
data from 114 studies, with more than 7000 healthy subjects
from 23 different countries). The results may have been
affected by significant differences in ambient temperatures
for some of the data, and also some of the subjects were
significantly underweight and may have been malnourished.
The age and weight range of subjects is wide, but the group
contains many more men than women, and a significant
number (about 1000) of the subjects were young male
Italian soldiers and cadets. The average subject in Schofield’s
data set would therefore be significantly younger, leaner and
fitter than an average Australian hospital patient. This may
193
S. Ferrie and M. Ward
Table 2 Harris–Benedict equation for estimating resting
energy expenditure (kcal/day)22
Men 66.5 + 13.8 W + 5.0 H - 6.8 A
Women 655.1 + 9.6 W + 1.8 H - 4.7 A
Coefficients are rounded to one decimal place.
W = weight (kg); H = height (cm); A = age (year).
mean that the equations overestimate requirements15,16 even
in young healthy Australian men.17 Other validating studies
have suggested that it may overestimate for those with low
requirements and underestimate for those with high require-
ments, deviating towards the mean for both.14 In 1991, a
British panel of experts, the Panel on Dietary Reference
Values, published a modified version of the Schofield equa-
tion for use in Britain.18 They added data from an additional
451 European subjects, particularly from older age groups,
and also excluded some of Schofield’s original data which
were ‘collected in the tropics’ and were not felt to reflect the
requirements of better-nourished British people. The origi-
nal data set may in fact have been more appropriate for
multicultural Australia; however, the modifications affect
only the older (over 60 years) age group. In any case, the
majority of Australian dietitians are likely to be using the
original, unmodified equations, because these are generally
the ones to be found in textbooks and other widely used
resources, such as the Dietitians’ Pocketbook,19 the previous
Recommended Dietary Intakes for Use in Australia20 and the
Nutrient Reference Values for Australia and New Zealand,
which replaced it.21
Harris–Benedict equation22
This equation was developed from a single smaller study,
with only 239 subjects, all healthy Americans. The partici-
pants may not be reflective of modern Australians because
they were relatively young (average age 29 ⫾ 11 years) and
lean (average body mass index 21 ⫾ 3 kg/m2). Repeated
measurements were made in each subject, with careful atten-
tion to factors such as subject inactivity; however, the limi-
tations of the testing conditions mean that some subjects
may not have been in a true ‘basal’ state, leading to over-
estimation of their energy needs.8,15 The Harris–Benedict
equation (Table 2) is thought to overestimate requirements
in healthy people, perhaps by 5% in men or 15% in
women.23–25 A disadvantage of this equation is that it requires
both weight and height, which may often not be available.
However, as it remains the most commonly used equation in
the world, particularly in the USA, it is essential to be famil-
iar with it when assessing the medical literature.
Mifflin–St Jeor equation26
This equation used 498 healthy adult subjects with a wide
range of ages and weights (about half of the subjects were
obese) and measured resting metabolic rate. The equation
uses actual weight, and notably it predicts significantly lower
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Journal compilation © 2007 Dietitians Association of Australia
Table 3 Mifflin–St Jeor equation for estimating resting
energy expenditure (kcal/day)26
Men 10 W + 6.25H - 5 A + 5
Women 10 W + 6.25H - 5 A - 161
W = weight (kg); H = height (cm); A = age (year).
requirements when weight is very high, compared with the
Schofield and Harris–Benedict equations. An advantage of
the Mifflin–St Jeor equation (Table 3) is that it is very simple
and easy to remember; however, like the Harris–Benedict
equation, it requires values for both weight and height.
Because of its wider range of subjects, it is considered to
reflect the requirements of the modern US population with
less estimation bias than other equations, and has recently
been endorsed by the American Dietetic Association.27 Its
use may increase in those populations among whom obesity
is becoming more common, but it does not yet appear to be
in common use in Australia1 and has not been subjected to
as much critical scrutiny as the older equations, having been
developed more recently. Further research may help estab-
lish whether it will be of lasting use in practice.
Activity and injury factors
All three of the equations above were developed using
healthy subjects, and may not accurately reflect the
requirements of hospitalised patients. They estimate only
basal or resting requirements, and therefore, it is customary
to make adjustments to the value obtained, to allow for
energy expended in activity and for the increased require-
ments due to illness. In practice, these adjustment factors
are often applied in different ways. Typically, the result
from the equation is multiplied by an activity factor (which
may be only 1.0 for a sedated patient lying still in bed) and
a stress or injury factor pertaining to the individual
patient’s condition. There is no evidence to support the
less-common practice of adding the activity and stress
factors before multiplying by the basal energy expenditure.
It may be based on different assumptions about how activ-
ity and stress would increase requirements.
The activity and stress factors were not developed by the
authors of the equations, but have been suggested by
researchers investigating total energy expenditure in differ-
ent states of illness or exercise. Table 4 lists activity factors
derived from the FAO/WHO/UNU Expert Consultation
Report and from a variety of other studies, mostly in healthy
people.13,28–33 Physical activity levels (PALs) are obtained by
measuring total energy expenditure in free-living individuals
and dividing by their BMR. This produces a multiple of the
BMR that expresses the average energy requirement for that
individual’s level of daily activity. When the measured energy
cost of a particular activity (climbing a ladder, for example)
is expressed as a multiple of BMR, this is called the physical
activity ratios (PARs) for that activity. Both PALs and PARs are
expressed as a multiple of the BMR, and are therefore
affected by any errors in measurement of BMR and total
© 2007 The Authors
 Back to basics: estimating energy requirements

Table 4 Activity factors for adult hospital patients13,28–33

resting (lying or sitting) 1.0–1.4 ¥ BMR
lying still, sedated or asleep 0.9–1.1
lying still, conscious 1.0–1.1
bedrest (moving self around bed) 1.15–1.2
sitting out of bed long periods 1.1–1.3
mobilising occasionally on ward 1.15–1.4
sedentary/light activity (standing for long periods) 1.4–1.6
mobilising frequently on ward 1.4–1.5
+regular, intensive physiotherapy 1.5–1.6
moderate activity (continuous movement/slow walking) 1.6–1.8
Factors in bold were obtained in healthy, free-living people.
BMR = basal metabolic rate.

energy expenditure.34 The PAR and PAL values are generated
from non-fasting subjects, so they include the TEF: this
means that an additional factor for TEF is not necessary
when using these as activity factors to predict an individual’s
energy requirement. Illness may have an effect on TEF: the
thermic response to nutrition can be increased in stress
situations, while continuous tube feeding may reduce TEF
close to the fasting level.9 It is important to consider that
illness and sedation cause a decrease in activity, so the activ-
ity component of total energy expenditure is likely to be
lower for a hospital patient than for a healthy person per-
forming the same activity. For example, studies of healthy
people with sedentary jobs found that their activity factor
averaged 1.5–1.7,29,35 while Elia reports a variety of studies
showing activity factors of only 1.15–1.3 in free-living
people with chronic illnesses, and 1.0–1.2 in hospitalised
people with acute diseases.28
Although illness tends to cause a decrease in physical
activity, it can also cause an increase in energy requirements,
by several different mechanisms. For example, inflammatory
or infective illness can increase the BMR. Large wounds,
such as in burn injury, cause loss of heat and body tissue. A
fever may increase energy expenditure by about 10% of BMR
for every centigrade degree above normal body tempera-
ture,36 while inducing hypothermia (such as after stroke or
cardiac arrest) decreases energy expenditure.37 Pain and
stress, too, increase energy expenditure, while sedation and
pain control can decrease it. Energy expenditure is reduced
further with heavier sedation.38
Since the early studies of energy expenditure were pub-
lished, changes in patient care (particularly in the critically
ill) such as improved pain management and respiratory
support, avoidance of overfeeding, and more effective treat-
ment of infections, have reduced the impact of illness on
energy consumption. This means that older recommenda-
tions for injury factors are mostly too high. Newer research
has also revealed a surprisingly wide variation in metabolic
rates of patients with conditions that were previously
assumed to be consistently hypermetabolic, such as can-
cer39 and sepsis.40,41 Such patients may have BMRs that are
close to normal, or even below normal, and even where
hypermetabolism occurs, it may be short-lived, peaking
within a few days.28 Unfortunately, the injury factors that
are still in wide use (and which still appear in many text-
books) are those from the original classic paper by Long
et al. from 1979,42 and use of these may significantly over-
estimate requirements, as indicated by more recent
studies.28,43–45 One of the more comprehensive approaches
is the study by Barak et al.,43 who derived injury factors for
the critically ill using indirect calorimetry and compared
them with existing factors in the literature. The paper
by Elia28 is a compilation of energy expenditure data
for a variety of both acute and chronic illnesses. Table 5
displays some injury factors based on these recent
studies.
The studies that derived these injury factors have most
commonly used the Harris–Benedict equation, and conse-
quently it has been argued that the factors are not valid to
use with other equations. However, the injury factors rep-
resent the estimated degree of hypermetabolism as a mul-
tiple of the BMR, so in theory they should be applicable to
any equation that accurately estimates BMR. In reality,
none of the equations is free of bias or error, and this error
may be increased if the injury factors are treated as fully
transferable between equations. Even with equations
known to have a similar bias (such as the Schofield and
Harris–Benedict equations, which both tend to overesti-
mate BMR) conservative selection of activity and injury
factors may be necessary, to avoid overfeeding. Careful
evaluation of the individual patient, with attention to bio-
chemical parameters (such as albumin, C-reactive protein)
and clinical signs (such as body temperature, minute ven-
tilation, cardiac output, weight changes), can also help
identify whether hypermetabolism is likely, justifying the
use of a larger injury factor.
In critically ill patients, even when the energy require-
ment is significantly increased, it may be difficult, and even
inappropriate, to meet these needs. Stress metabolism can
interfere with utilisation of the extra energy, leading to an
increased risk of overfeeding, and undesirable complica-
tions.46 Conservative provision of nutrition support, or
even deliberate underfeeding, is increasingly being recom-
mended in these patients47,48 despite their known increase
in requirements.

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S. Ferrie and M. Ward
Table 5 Stress/injury factors for adult hospital patients28,43–45
Medical
(e.g. inflammatory bowel disease, liver or pancreatic disease)
Surgical
(e.g. transplant, fistula)
Cancer
(e.g. tumour or leukaemia)
Trauma
(e.g. skeletal or head injury or minor burns)
Sepsis
or other major infection
Major burns
Critical illness and/or major surgery/trauma
• With mechanical ventilation
• After the first week, for next 2–3 weeks (note limitations on utilisation
and risk of overfeeding)
Table 6 Ireton–Jones equation for estimating total energy
expenditure (kcal/day)49
Non-ventilated patients
629 - 11 A + 25 W - 609 O
Ventilated patients
1784 - 11 A + 5 W + 244 S + 239 T + 804 B
A = age (year); W = weight (kg).
O = 1 if obese (body mass index >27); 0 otherwise.
S = 1 if patient is male; 0 otherwise.
T = 1 if trauma (include major surgery) is present; 0 otherwise.
B = 1 if burns are present; 0 otherwise.
Ireton–Jones equation49
This is one of the few equations available that have been
developed and validated for use in hospitalised patients,
rather than healthy people, and is notable for its lower
estimates for heavier patients when compared with other
commonly used equations.50 The original equation (Table 6)
was developed from a single study of 200 hospitalised
patients, including patients with trauma and burns. Advan-
tages of the Ireton–Jones equation include the fact that it
uses the patient’s actual weight, does not require a value for
height, predicts total energy expenditure (therefore does not
require activity or stress factors), and is subject to ongoing
review by its authors and, therefore, may be more reflective
of contemporary medical management than other, older
equations. It takes into account specific clinical conditions,
such as mechanical ventilation or trauma. However, it is
important to be aware of the many assumptions made in
developing this equation, which affect its use and interpre-
tation. These include:
1 A patient is critically ill only while ventilated.
2 All burns and trauma are of the same severity, and affect
energy requirement during the ventilated/critical illness
phase only. This means that the equation does not account
for an anabolic period of convalescence.
3 All modes of ventilation have the same impact on energy
requirements.
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Journal compilation © 2007 Dietitians Association of Australia
1.1–1.2
1.1–1.4
1.1–1.4
1.2–1.4
1.3–1.4
1.4–1.6
1.2–1.4
>1.6–1.8
4 All obese patients have the same body size and body
composition at a given weight.
Several study groups have tested this equation on their
own patients, usually by comparing the results of the equa-
tion (which estimates total energy expenditure) with indirect
calorimetry measures of resting expenditure. This may be
appropriate in a sedated critically ill patient, but is not a valid
comparison if the patient has significant activity. Unsurpris-
ingly, the Ireton–Jones equation produces a result that is
significantly greater than the resting energy expenditure in
such situations.51,52 In a number of studies of sedated
mechanically ventilated patients, the Ireton–Jones equations
performed better than other equations (including the
Harris–Benedict equation), but did show some bias towards
underestimation.50,53–56 Two studies of acutely ill hospital
patients found that the Harris–Benedict equation used with
an injury factor was more accurate than the Ireton–Jones
equation. One of these studies looked at normal-weight ven-
tilated critically ill patients (using a factor of 1.2);55 the other
was in acutely ill obese patients and used an adjusted weight
value (with an injury factor of 1.3).57
OTHER CONSIDERATIONS
Adjusting weight
Which value to use for body weight has been a controversial
issue for some time. All of the equations discussed above
were developed using the actual weight of each subject, and
the authors make no recommendations regarding the use of
any other value. Use of an arbitrary adjusted weight value
introduces an additional source of possible error, increasing
the variability of the result.58 However, there are many situ-
ations in which the patient’s weight differs significantly from
normal, and the use of the actual weight value can lead to
unacceptable errors in estimating requirements.59–61 It may
therefore be appropriate sometimes to use a different value
in the calculation.
If the patient is underweight, the use of the patient’s
current weight is likely to be the best way to estimate current
© 2007 The Authors

energy requirements. However, in some patients, such as the
critically ill, this may be an underestimate.59 If it is appro-
priate to aim for weight gain, ideal weight can be used to
estimate an ideal energy intake. However, this approach may
be too aggressive for frail or unstable patients, and it may be
necessary to select a more conservative goal weight at first,
particularly in very underweight people. Close monitoring
is desirable to ensure that the patient does not develop
overfeeding-related complications. The risk of overfeeding is
increased during illness, as stress metabolism alters fuel utili-
sation.46 During this time, any weight gained will be mainly
fat and fluid.62 As a guide, weight change (either gain or loss)
is not an appropriate goal during the period that an injury/
stress factor applies to the patient.
If the patient is overweight or obese, or severely oedema-
tous, using the actual weight can lead to an overestimation of
the patient’s requirements. The metabolic activity of adipose
tissue is lower compared with other tissue,63,64 so an obese
patient has a lower metabolic rate per kg body weight. It has
been suggested that the ratio of lean tissue to fat tissue
changes as weight increases. That is, an increase in adipose
tissue is supported by an increase in muscle and organ mass
but, at the point of obesity, the fat stores are increasing
disproportionately.65,66 Studies using indirect calorimetry
have obtained conflicting results on this point.23–26,43,67,68
Some suggest that the ratio of lean tissue to fat tissue remains
the same as weight increases, even in obesity; others indicate
that equations using actual weight can grossly overestimate
requirements in the obese. Use of an adjusted weight value is
clearly problematic,69 but may still be appropriate in order to
avoid overestimating the patient’s requirements in cases
where overfeeding is particularly undesirable. These may
include situations such as:
1 Where an obese or oedematous patient is not mobilising,
such as bedbound or critically ill patients. An ambulant
obese or oedematous patient has greater energy expendi-
ture in everyday activities as a result of moving the extra
body weight around. If the patient is not mobilising, this
contribution to energy expenditure is absent.
2 Where overfeeding may be difficult to detect and is very
undesirable, such as in mechanical ventilation or other
respiratory compromise, or patients receiving parenteral
nutrition.
3 Where the patient is sedentary in the long term, and
muscle is not being maintained by activity (therefore, any
extra weight is more likely to be adipose tissue), such as
elderly patients or those who are otherwise mobility
disabled.
4 In patient groups with known reduced energy needs, such
as head injury patients after the acute period.
Usually the adjustment consists of using the ideal weight
plus 25–50% of the excess weight.43,57,67 For example, a
patient weighing 100 kg whose ideal weight is 60 kg would
have an adjusted weight value of 70–80 kg for use in pre-
dictive equations. Ideally, the choice of weight adjustment
should be based on a physical assessment of the patient’s
tissue stores. A very muscular patient can be ‘overweight’ yet
be very lean, and it would be appropriate to use actual
© 2007 The Authors
Journal compilation © 2007 Dietitians Association of Australia
Back to basics: estimating energy requirements
weight in predicting the energy requirement. For most
patients requiring an adjusted weight calculation, an average
between ideal and actual weights would be appropriate,43,57
while in extreme adiposity, where lean tissue stores appear
depleted, or in oedema, where lean tissue is not contributing
to the extra weight, an even lower adjusted weight might
better reflect the patient’s reduced metabolic activity.67 Using
an adjusted weight value requires caution, as it increases the
risk of underfeeding in overweight patients.27 If the patient is
ambulant, it may be more appropriate to use an obesity-
validated equation, such as the Mifflin–St Jeor equation (if
height information is available) or the Ireton–Jones equation
using the obesity factor.
Total energy or ‘non-protein calories’?
In the past it has been suggested (most commonly in the
context of parenteral nutrition) that a patient’s energy
requirements should be provided as ‘non-protein calories’, in
order to spare the protein for healing and anabolism.
However, predictive equations estimate the consumption
rate of all energy, not just non-protein energy. If it is assumed
that the estimated requirement refers only to the non-protein
energy requirement, overfeeding will result, and beyond a
certain point, giving extra energy will not improve protein
sparing at all. As long as the protein requirement is met, it is
sufficient to provide the estimated energy needs as the total
energy input.70,71
CONCLUSION
The use of predictive equations for energy requirements has
many pitfalls. There is little benefit in blindly applying an
equation without paying attention to the individual charac-
teristics of the patient and the situation. This can affect the
credibility of the nutrition support dietitian, attracting terms
like ‘mumbo-jumbo’ and ‘dietitian’s fudge factor’. An under-
standing of the origins and limitations of the equations is
important for any dietitian who uses them.
The complex appearance of the equations unfortunately
seems to give them more authority than they deserve. An
equation is not a magic formula, and will not transform
incorrect or inaccurate data into a useful result. For example,
using an equation with both an estimated height and an
estimated weight is probably no better than just making a
conservative guess about an appropriate feed rate, or
approximating requirements with a simple rule of thumb
(such as a ‘calories-per-kilo’ method). Expressing the pre-
dicted requirement as a range, rather than a fixed value, may
help avoid implying an unrealistic level of accuracy.
Most importantly, it is often forgotten that the equation
only provides a suggested starting point for energy provision:
the aim is not just to obtain the ‘right answer’ at the begin-
ning and then walk away. Ongoing monitoring of the patient
is essential, and this may involve regular re-estimation of
requirements and adjustment of the feeding regimen as the
patient’s condition changes. An equation cannot replace
other forms of assessment, such as physical examination,
197
S. Ferrie and M. Ward
and is no substitute for quality patient care. However, when
used by an informed and experienced practitioner, predic-
tive equations can still be a valuable and time-saving tool,
and retain a role in a dietitian’s evidence-based clinical
practice.
ACKNOWLEDGEMENTS
The authors wish to acknowledge Kathryn Marshall, Nicola
Riley and Kellie Draffin for their valuable contributions to
this paper.
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