Susan Fullmer

Evidence analysis library review of best practices for performing indirect calorimetry in healthy and non-critically ill individuals.

When measurement of resting metabolic rate (RMR) by indirect calorimetry is necessary, following evidence-based protocols will ensure the individual has achieved a resting state. The purpose of this project was to update the best practices for measuring RMR by indirect calorimetry in healthy and non-critically ill adults and children found the Evidence Analysis Library of the Academy of Nutrition and Dietetics. The Evidence Analysis process described by the Academy of Nutrition and Dietetics was followed. The Ovid database was searched for papers published between 2003 and 2012 using key words identified by the work group and research consultants, studies used in the previous project were also considered (1980 to 2003), and references were hand searched. The work group worked in pairs to assign papers to specific questions; however, the work group developed evidence summaries, conclusion statements, and recommendations as a group. Only 43 papers were included to answer 21 questions about the best practices to ensure an individual is at rest when measuring RMR in the non-critically ill population. In summary, subjects should be fasted for at least 7 hours and rest for 30 minutes in a thermoneutral, quiet, and dimly lit room in the supine position before the test, without doing any activities, including fidgeting, reading, or listening to music. RMR can be measured at any time of the day as long as resting conditions are met. The duration of the effects of nicotine and caffeine and other stimulants is unknown, but lasts longer than 140 minutes and 240 minutes, respectively. The duration of the effects of various types of exercise on RMR is unknown. Recommendations for achieving steady state, preferred gas-collection devices, and use of respiratory quotient to detect measurement errors are also given. Of the 21 conclusions statements developed in this systemic review, only 5 received a grade I or II. One limitation is the low number of studies available to address the questions and most of the included studies had small sample sizes and were conducted in healthy adults. More research on how to conduct an indirect calorimetry measurement in healthy adults and children and in sick, but not critically ill, individuals is needed.

Factors affecting the severity of necrotizing enterocolitis

Abstract Objective: The severity of necrotizing enterocolitis (NEC) ranges from mild to rapidly fatal. However, the factors determining the severity are not known. Our objective was to identify statistical associations with NEC severity using a large database. Method: We conducted a retrospective, multi-institutional, multiyear, study of neonates with confirmed NEC. Results: Two-hundred-twenty neonates with Bell’s stage ≥ II NEC had 225 NEC episodes (157 stage II and 68 stage III). In the 3 d before NEC was diagnosed, those who went on to stage III disease were more likely to have elevations in C – reactive protein (p < 0.0001), immature to total neutrophil ratio (p = 0.0005), and mean platelet volume (p = 0.0001), and low pH (p < 0.0001) and platelet count (p < 0.0001). Regression analysis indicated higher odds that NEC would be severe if there was an antecedent RBC transfusion (p < 0.0001) or if the first feedings were not colostrum (p = 0.017). The two factors best predicting death from NEC were; (1) a low pH (p = 0.0005) and (2) lack of early colostrum (p = 0.003). Conclusions: Strategies that reduce the severity of NEC would lower costs and improve outcomes. This study suggests that testable theories to accomplish this include means of; (1) reducing transfusions and (2) assuring early colostrum feedings.

Professional Involvement is Associated with Increased Job Satisfaction among Dietitians

This study explored a relationship between professional involvement and job satisfaction among dietitians. A random sample of 2,600 employed registered dietitians (RDs) received a 55-item questionnaire including a standardized measure of job satisfaction. The response rate was 67.3%; 50.8% were useable (n = 1,321). Ninety-two percent of RDs reported job satisfaction. The mean score was 68.8 +/- .28 (possible range: 18-90), with scores over 54 indicating job satisfaction. A positive relationship was found between job satisfaction and markers of professional involvement. Additionally, six characteristics related to professional involvement were: having had a mentor, being a mentor, self-assessed high professional involvement, full-time employment, high annual income, and increased hours worked per week. There was also a positive relationship between markers of professional involvement and employer support. We conclude that, overall, RDs are satisfied with their jobs and that greater professional involvement is related to greater job satisfaction.

Comparing Steady State to Time Interval and Non–Steady State Measurements of Resting Metabolic Rate

The 2 most common methods to determine resting metabolic rate (RMR) with indirect calorimetry are steady state (SS) and time intervals. Studies have suggested SS more accurately reflects RMR, but further research is needed. Our objective was to compare the bias, precision, and accuracy of SS to time intervals and non-SS measurements in a healthy adult population. Seventy-seven participants were measured for 45 minutes using a Quark RMR. Inclusion criteria included healthy participants aged 18–65 years. Pregnant and lactating women were excluded. Paired t tests compared differences between measures. Bland-Altman plots were used to determine precision. Bias occurred if there was a significant difference between the means. Accuracy was determined by counting the number of absolute differences between SS compared with non-SS and time intervals that were <75 calories. Of 77 participants, 84% achieved SS, and 95% achieved SS by minute 30. Most differences between SS and time intervals were statistically but not practically significant. Bland-Altman plots showed SS measurements were generally lower than any time interval, suggesting SS is more indicative of RMR. Non-SS was significantly more biased (P = .0005), less precise (spread of limits of agreement was 269 calories), and less accurate (65%) than SS. We conclude that non-SS is not equivalent to SS. We also conclude that using 5-minute SS is more indicative of RMR than any time interval that was tested in healthy populations. If SS cannot be achieved, we recommend repeating the measurement.

Handgrip Strength and Malnutrition (Undernutrition) in Hospitalized Versus Nonhospitalized Children Aged 6–14 Years

Background: Diagnosing undernutrition in hospitalized pediatric populations is crucial to provide timely nutrition interventions. Handgrip strength (HGS), a measurement of muscle function, is a reliable indicator of undernutrition. However, limited research exists on HGS in hospitalized pediatric patients. The primary aim of this study was to determine if HGS differed between hospitalized children within 48 hours of admission and nonhospitalized children. A secondary purpose was to describe the association of HGS with height, weight, body mass index (BMI), mid upper arm circumference (MUAC), activity level, disease severity, nutrition risk, and nutrition intervention. Methods: One hundred nine hospitalized and 110 nonhospitalized patients aged 6–14 years participated in this cross-sectional nonequivalent control group design study. Weight, height, MUAC, and HGS were measured within 48 hours of hospital admission for the hospitalized group or immediately following a well-child visit for the control group. Results: Based on analysis of covariance, the HGS was estimated to be 12.4 ± 0.37 kgF (mean ± SE) for hospitalized subjects and 13.1 ± 0.37 for nonhospitalized subjects (P = .2053). HGS was associated with age (P < .0001), height (P < .0001), dominant hand (P < .0001), and MUAC z scores (P = .0462). Conclusion: HGS was not significantly different between hospitalized and nonhospitalized participants, although anthropometric measurements were similar between groups. A strong relationship was demonstrated between HGS and BMI and MUAC z scores. Further research is needed that examines serial HGS measurements, feasibility in hospitalized patients, and the association of HGS measurements and nutrition risk.