1.

Calories and protein for cancers and HIV—what are the latest recommendations

Cancer

CALORIES:

(NCM)1

Due to the limited evidence supporting methods to estimate energy needs in patients with cancer, many
clinicians use the following parameters (Russell, 2006; Hurst, 2006; Bosaeus, 2002):

● 25 to 30 kcal/kg body weight for non-ambulatory or sedentary adults

● 30 to 35 kcal/kg body weight for hypermetabolic patients, for weight gain, during the first month
after allogeneic hematopoietic stem cell transplant, or for an anabolic patient
● 35 kcal/kg body weight and above for hypermetabolic or severely stressed patients, patients with
acute graft-versus-host disease, during head and neck chemoradiation, or for those with
malabsorption. Avoid calorie provision above 35 kcal/kg prior to start of cancer treatment

(Krause)2

(Clinical Nutrition Journal)3

(Clinical Therapeutics Calories & Protein)4

PROTEIN:

(NCM)1

Suggested calculations for estimating protein needs include:

● 0.8 to 1.0 g/kg normal maintenance (Hurst, 2006)

● 1.0 to 1.2 g/kg body weight, non-stressed patient with cancer
● 1.2 to 1.5 g/kg body weight, patients undergoing treatment
● 1.5 to 2.0 g/kg stem cell transplant (Hurst, 2006)
● 1.5 to 2.5 g/kg body weight for patients with increased protein needs such as protein-losing
enteropathies or wasting

(Krause)2

For example, protein needs for a catabolic client may be 1.2 g/kg/day or more, and protein needs for an
individual undergoing a hematopoietic cell transplant may be 1.5 g/kg/day. Daily protein requirements
generally are calculated using actual body weight rather than ideal body weight.

(Clinical Nutrition Journal)3

EVIDENCE:

(NCM Calories)1

Energy needs should be routinely assessed and reassessed during the course of treatment, and the
nutrition interventions should be adjusted based on the nutritional response of the patient.
The Academy of Nutrition and Dietetics Oncology 2013 Evidence-Based Guideline included the following
major recommendations related to measuring or estimating energy needs in cancer patients:

Use of indirect calorimetry to measure REE [resting energy expenditure] is more accurate than estimation
in early stage and advanced metastatic breast cancer patients. If measurement of REE is not possible or
not thought to be imperative, use the HBE [Harris-Benedict equation] to estimate calorie requirements.
Limited evidence indicates that the mean estimated REE was comparable to measured REE in these
populations. No research was available to compare HBE using individual error or to compare HBE with
other predictive equations in these populations. (Weak evidence)

Use of indirect calorimetry to measure resting energy expenditure (REE) is more accurate than estimation
in patients with advanced head and neck cancer undergoing chemoradiation therapy. If measurement of
REE is not possible or not thought to be imperative, use the Harris Benedict Equation (HBE) to estimate
calorie needs. However, limited evidence indicates that HBE underestimates REE in this population.
(Weak evidence)

Use indirect calorimetry to measure REE for adult patients with hematologic malignancies undergoing
allogeneic HCT. When indirect calorimetry is not available, limited evidence indicates that the estimated
energy requirements are 30-35 kcal per kg per day during the first month post-transplant, and may be
higher during acute GVHD and/or for patients receiving >75% of their total daily energy intake via PN.
(Fair evidence)

Use of indirect calorimetry to measure REE is more accurate than estimation in patients with non-small
cell lung cancer (NSLC) cancer undergoing chemotherapy. If measurement of REE is not possible or not
thought to be imperative, use HBE to estimate calorie needs. However, limited evidence indicates that the
HBE may underestimate energy needs by an average of 12-13%. (Weak evidence)

(NCM Protein)1

The Academy of Nutrition and Dietetics Oncology Evidence-Based Guidelines state that protein needs
are increased above the Recommended Dietary Allowance ( RDA ) of 0.8 g/kg body weight in head and
neck cancer patients undergoing radiation therapy as well as patients with hematological malignancies
undergoing allogeneic hematopoietic stem cell transplants (HCT).

The protein needs for patients with hematologic malignancies undergoing allogeneic HCT are higher than
the RDA. Limited evidence suggests that more than 2.2 g protein per kg may be needed to maintain
nitrogen balance. Further research is needed to define protein requirements in this population. (Fair
evidence)

The protein needs for patients with head and neck cancer undergoing radiation therapy may be higher
than the RDA. Limited evidence indicates patients consuming the RDA for protein experienced a
significant decrease in weight and LBM during treatment. More defined protein intervention studies are
needed. (Weak evidence)

(Krause Calories)2

Determining individualized energy needs is vital to helping people maintain an energy balance and
achieve a healthy weight; it is also vital to preventing unintentional weight gain or loss associated with
cancer and cancer treatment. Methods used to estimate energy requirements for adults include using
standardized equations or measuring resting metabolic rate us- ing indirect calorimetry. To ensure that
adequate energy is being provided, the individual’s diagnosis, presence of other diseases, intent of
treatment (e.g., curative, control, or palliation), anticancer therapies (e.g., surgery, che- motherapy,
biotherapy, or radiation therapy), presence of fever or infection, and other metabolic complications such
as refeed- ing syndrome must be considered.

(Krause Protein)2

An individual’s need for protein is increased during times of illness and stress. Additional protein is
required by the body to repair and rebuild tissues affected by cancer treatments and to maintain a healthy
immune system. Adequate energy should be provided, or the body will burn its lean body mass as a fuel
source. The degree of malnutrition, extent of disease, degree of stress, and ability to metabolize and use
protein are factors in determining protein requirements. For example, protein needs for a catabolic client
may be 1.2 g/kg/day or more, and protein needs for an individual undergoing a hematopoietic cell
transplant may be 1.5 g/kg/day. Daily protein requirements generally are calculated using actual body
weight rather than ideal body weight.

(Clinical Nutrition Journal Calories)3

While REE is increased in many cancer patients, when TEE is considered, this value appears to be lower
in patients with advanced cancer when compared to predicted values for healthy individuals; the main
cause appears to be a reduction in daily physical activity. However, it needs to be considered that small
differences between energy intake and energy expenditure will result in further weight loss. Sparse data
obtained by using a wearable device to monitor daily activity indicate that TEE of weight-stable leukemic
patients and of weight-losing bedridden patients with gastrointestinal tumours is about 24 and 28
kcal/kg/day, respectively). In conclusion, it appears sensible to initiate nutrition therapy assuming TEE to
be similar to healthy controls. TEE may be estimated from standard formulas for REE and standard
values for physical activity level (PAL). Alternatively, TEE may be predicted roughly by using rules of
thumb and assuming TEE to be some 25-30 kcal/kg depending on the patient's performance status. By
these rough estimates TEE will be overestimated in obese and underestimated in severly malnourished
patients. More accurately, REE may be determined by indirect calorimetry and physical activity by
wearable devices. It is essential, however, in the course of treatment to subsequently adapt the provision
of energy according to clinical effects on body weight and muscle mass.

(Clinical Nutrition Journal Protein)3

The evidence to support this statement is moderate because the existing studies focused on metabolic
endpoints and benefits and did not address clinical end-points. However metabolic investigations showed
that an elevated protein intake promoted muscle protein anabolism in patients with cancer. This potential
benefit, in our opinion, may justify using a high protein diet. The optimal nitrogen supply for cancer
patients has not been determined and the recommendations of experts range between a minimum protein
supply of 1 g/kg/day and a target supply of 1.2-2 g/kg/day, especially if inactivity and systemic
inflammation are present. Old age, inactivity and systemic inflammation are known to induce “anabolic
resistance”, i.e. decreased responsiveness of protein synthesis to anabolic stimuli). Evidence-based
recommendations for chronically ill older subjects call for a protein supply of 1.2-1.5 g/kg/d.
(Clinical Therapeutics Calories & Protein)4

To detect nutritional disturbances at an early stage, ESPEN recommends that nutritional intake, weight
changes, and BMI be evaluated regularly, beginning at the time of initial cancer diagnosis. In patients
found to be at nutritional risk on screening, objective and quantitative assessment of nutritional intake,
nutritional impact symptoms, muscle mass, physical performance, and the degree of systemic
inflammation is recommended. The total energy expenditure of patients with cancer, if not measured
individually, can be assumed to be similar to that of healthy subjects, generally ranging between 25 and
30 kcal/kg per day, and protein intake should be > 1 g/kg per day and, if possible, up to 1.5 g/kg per day.

RESOURCES:

1. Nutrition Care Manual. Comparative standards. Nutrition Care Manual.

https://www.nutritioncaremanual.org/topic.cfm?
ncm_category_id=1&lv1=22938&lv2=255467&lv3=268808&ncm_toc_id=268808&ncm_heading=
Nutrition%20Care. Published unknown. Accessed April 6, 2020.

2. Mahan, L., Raymond, J. Krause’s Food & The Nutrition Care Process. Elsevier Inc; 2017

3. Arends, J. et al. ESPEN guidelines on nutrition in cancer patients. Clinical Nutrition. 2017;36:11-
48. https://www.clinicalnutritionjournal.com/article/S0261-5614(16)30181-9/pdf. Accessed April 6,
2020.

4. Yalcin, S. et al. Nutritional aspects of cancer care in medical oncology patients. Clinical
Therapeutics. 2019;41:2382-2396.
https://www.sciencedirect.com/science/article/pii/S0149291819304837. Accessed April 6, 2020.

HIV

CALORIES:

(NCM & Krause)1 & 2

No defined perimeters. The registered dietitian should use clinical judgment and consider several factors
when determining the energy needs of adults and children with HIV infection to maintain a healthy body
weight. Although research reports increased resting energy expenditure (as much as 5% to 17%) in
people with HIV infection, total energy expenditure may be similar to that of healthy control subjects.
(WebMD)3***

● Consume 17 calories per pound of your body weight if you've been maintaining your weight.
● Consume 20 calories per pound if you have an opportunistic infection.
● Consume 25 calories per pound if you are losing weight.

(Associations of Nurses in AIDs Care)4***

● Stable Persons Living With HIV (PLWH): 20-30 kcal/kg/body weight

● Symptomatic PLWH: 35 kcal/kg/body weight

PROTEIN:

(NCM)1

● Adequate Weight; Not Malnourished: 0.8 g/kg/body weight

● Opportunistic Infection: higher dietary protein intake may be warranted; however, no studies have
demonstrated increasing protein intake to be beneficial even during this time of opportunistic
infection

(Krause)2

● Adequate Weight; Not Malnourished: 0.8 g/kg/body weight

● Opportunistic Infection: Additional 10% increase in protein intake is recommended because of
increased protein turnover
● If other comorbidities such as renal insufficiency, cirrhosis, or pancreatitis are present, protein
recommendations should be adjusted accordingly

(WebMD)3***

● Aim for 100-150 grams a day, if you are an HIV-positive man.

● Aim for 80-100 grams a day, if you are an HIV-positive woman.
● If you have kidney disease, don't get more than 15%-20% of your calories from protein; too much
can put stress on your kidneys

(Associations of Nurses in AIDs Care)4***

● Stable Persons Living With HIV (PLWH): 0.8 - 1.25 g protein/kg/body weight
● Symptomatic PLWH: 1.5 - 2.0 g protein/kg/body weight

EVIDENCE:
(NCM Calories)1

Resting energy expenditure (REE) may be increased by as much as 5% to 17% in people with HIV
infection, compared with healthy individuals (Academy EAL, 2010; Kosmiski, 2011). Activity level can be
significantly decreased in HIV-infected individuals, leading to overall total energy expenditure similar to
that of healthy individuals. However, adults with HIV-1 infection show increasing REE with increasing
severity of illness, especially with secondary infection and more advanced HIV disease. Factors related to
increased energy needs in people with HIV infection include stage of disease, opportunistic infections and
comorbidities, inflammation, and effects of medications. Maintenance of energy balance is an important
feature of medical nutrition therapy efforts.

In addition, it has been noted that within the first 12 months of initiation of antiretroviral therapy (ART),
weight gain occurs and could increase the risk of prevalence of overweight/obesity in HIV-infected
individuals, so this trend should be monitored and dietary recommendations to limit weight gain may be
necessary. The greatest clinically significant increase in prevalence of overweight/obesity in HIV within 12
months of newly initiated ART occurs in women (60% to 80%) when compared with a control group of
HIV-negative individuals; more weight gain was reported in those with lower pretreatment CD4 counts (<
200 cells/mm3).

(NCM Protein)1

According to the World Health Organization (WHO) guidelines, there is no evidence to support increased
dietary protein needs for people with HIV. If an individual has opportunistic infections, a higher dietary
protein intake may be warranted; however, no studies have demonstrated increasing protein intake to be
beneficial even during this time of opportunistic infection. Furthermore, evidence in the Academy of
Nutrition and Dietetics Evidence Analysis Library (EAL) states that although adding protein to diets may
be beneficial in the case of inadequate body cell mass, specific protein requirements, protein turnover,
and the effects of increasing protein intake have not been evaluated. Further research is needed in
people living with HIV (Academy EAL, 2010).

(Krause Calories)2

When determining energy needs, the clinician must establish if the individual needs to gain, lose, or
maintain weight. Other factors such as altered metabolism, nutrient deficiencies, severity of disease,
comorbidities, and OIs (opportunistic infections) should be taken into account when evaluating energy
needs. Calculating energy and protein needs for this population is difficult because of other issues with
wasting, obesity, HALS, and lack of accurate prediction equations. Some research suggests that resting
energy expenditure is increased by approximately 10% in adults with asymptomatic HIV. After an OI,
nutritional requirements increase by 20% to 50% in adults and children. Continuous medical and nutrition
assessment is necessary to make adjustments as needed. Individuals with well-controlled HIV are
encouraged to follow the same principles of healthy eating and fluid intake recommended for the general
population.

(Krause Protein)2
The current recommended dietary reference intake (DRI) is 0.8 g of protein per kilogram of body weight
per day for healthy individuals. Deficiency of protein stores and abnormal protein metabolism occur in HIV
and AIDS, but no evidence exists for increased protein intake over and above that necessary to
accompany the required increase in energy. For people with HIV who have adequate weight and are not
malnourished, protein supplementation may not be sufficient to improve lean body mass. However, with
an OI, an additional 10% increase in protein intake is recommended because of increased protein
turnover. If other comorbidities such as renal insufficiency, cirrhosis, or pancreatitis are present, protein
recommendations should be adjusted accordingly.

(WebMD)3***

Sources Referenced:
Nerad J. Clinical Infectious Diseases.
Tufts School of Medicine: "Lipodystrophy."
Tufts School of Medicine: "Why is good nutrition important in HIV?"
Tufts School of Medicine: "Building a high quality diet."
Tufts School of Medicine: "Nausea."
Tufts School of Medicine: "Diarrhea."
Association of Nutrition Services Agencies: "General Nutrition Requirements."
UCSF HIVInSite: "Diet and Nutrition."
Pasco County Health Department: "Putting the Pieces Together: A Companion Guide to Improving
Nutrition and Food Safety for Persons Living With HIV."

(Associations of Nurses in AIDs Care)4***

HIV-related wasting and weight loss are often due to one or more of four factors: a) reduced intake (e.g.,
anorexia, nausea); b) excessive nutrient losses (e.g., diarrhea, vomiting, malabsorption); c) metabolic
changes (e.g., hypermetabolism, cytokine mediators); and d) drug-nutrient interactions (e.g., altered
absorption, metabolism). To maintain protein status in stable PLWH, 0.8 to 1.25 g of protein per kilogram
of body weight and 20-30 calories per kilogram of body weight are recommended. For symptomatic
PLWH, 1.5 to 2.0 g of protein per kilogram of body weight and 35 calories per kilogram of body weight are
recommended. Caloric intake should be adjusted to achieve and maintain a healthy body weight.

RESOURCES:

1. Nutrition Care Manual. Comparative standards. Nutrition Care Manual.

https://www.nutritioncaremanual.org/topic.cfm?
ncm_category_id=1&lv1=20149&lv2=268740&ncm_toc_id=268740&ncm_heading=Nutrition
%20Care. Published unknown. Accessed April 6, 2020.

2. Mahan, L., Raymond, J. Krause’s Food & The Nutrition Care Process. Elsevier Inc; 2017

3. Robinson, J. Nutrition and HIV/AIDS. WebMD. https://www.webmd.com/hiv-aids/guide/nutrition-

hiv-aids-enhancing-quality-life#3. Last reviewed May 11, 2019. Accessed April 6, 2020.
a. ***May not be a reliable source
4. Keithley, J., Swanson, B. Nursing Guidelines: HIV and Nutrition. Associations of Nurses in AIDs
Care. http://www.nursesinaidscare.org/files/public/ANAC_nutr_pamphlet_WEB.pdf. Published
Unknown. Accessed April 7, 2020.
a. ***May not be a reliable source
2. ABW, latest thinking on this

What is Adjusted Body Weight (ABW)?

Adjusted body weight is used by some dietitians for obese or amputated patients when calculating energy
requirements. Adipose tissue is not as metabolically active as lean tissue, so using actual body weight in
equations to predict BEE for obese persons may result in an overestimation. Amputees are missing mass
that would typically affect their metabolism.

What are the most recent recommendations or latest thinking on this? (most recent
publications to least recent)

(2016)
Andrews, A., Pruziner, A. Guidelines for using adjusted vs unadjusted body weights when conducting
clinical evaluations and making clinical recommendations. Journal of the Academy of Nutrition
and Dietetics. 2016;117(7):1011-1015. DOI: https://doi.org/10.1016/j.jand.2016.07.003.

The objective of this analysis was to determine which calculation, Mozumdar or Osterkamp, was more
appropriate for clinical assessment and recommendation when using an adjusted body weight. A
secondary objective is to provide an example of appropriate application for use of an unadjusted weight in
this population.

Use of an unadjusted body weight significantly underestimated BMI relative to the both adjusted methods,
which may greatly impact clinical decision making and recommendations. Although using an adjusted
body weight is important when calculating BMI, the method used to estimate this weight also must be
considered because of the noted differences when using the Osterkamp and Mozumdar methods. The
Osterkamp method with rounding produced significantly higher BMI calculations when compared with the
Mozumdar method.

Use of an estimated proportion of the missing limb when using the Osterkamp method may greatly reduce
the error associated with this method when rounding up to the next most proximal joint. The rounding was
included in this study because this practice is commonly observed in similar studies and is used by
students and fellow clinicians in our clinical practice. For example, for a 90-kg patient who has a
transfemoral amputation, the practitioner often will use 16% for the proportion representing the missing
leg. If the patient has a short (eg, one-third of the original thigh) or long (eg, two-thirds of the original
thigh) residual limb, this value may greatly vary the calculated mass.

This analysis also demonstrated that some measurements, such as energy requirements, are best
completed using unadjusted weight. To accurately and appropriately estimate energy requirements,
practitioners should use actual body weight and not adjusted body weight. Adjusted body weights factor in
missing body mass; however, this “mass” is not metabolically active and, therefore, does not provide a
benefit to the patient.

(2015)
Kohn, J. Adjusted or ideal body weight for nutrition assessment? Journal of the Academy of Nutrition
and Dietetics. 2015;115(4):680. DOI: https://doi.org/10.1016/j.jand.2015.02.007.
According to the Academy’s Nutrition Care Manual, “there is no evidence that substituting adjusted or
ideal weight … results in improved accuracy.” It also states that many of the RMR equations were
developed using actual body weight. ABW will underestimate or overestimate RMR in patients depending
on their weight status. In the case of overweight and obese patients, RMR can be underestimated by as
much as 42% when using ABW with the Harris-Benedict equation.

The Academy’s Evidence Analysis Library (EAL) Adult Weight Management Guideline specifically
recommends using actual body weight and the Mifflin-St Jeor equation if RMR cannot be measured by
indirect calorimetry when estimating energy needs in non–critically ill patients. In cases with critical
illness, mechanical ventilation, and other conditions, alternative equations may need to be considered. In
most other circumstances, actual body weight is advocated when assessing energy, protein, and fluid
needs.

(2011)
Patil, P., Sucher, K., Hollenbeck, C., Brown, E. Evaluating the use of adjusted body weight for predicting
resting metabolic rate of overweight and obese patients. Journal of the American Dietetic
Association. 2011;111(9):A28. DOI: https://doi.org/10.1016/j.jada.2011.06.100.

The objective of this study was to assess the effectiveness of using adjusted body weight in predictive
equation for estimating resting metabolic rate (RMR) of obese and overweight individuals.

RMR was predicted by Mifflin-St Jeor and Harris-Benedict equations using current body weight (CBW),
ABW and ideal body weight (IBW). The calculated RMR was compared to RMR measured by indirect
calorimeter.

Harris-Benedict equation using ABW underestimated RMR 67% in obese women. Mifflin St Jeor using
ABW underestimated RMR 100% in obese women and 50% in overweight subjects (men and women).
Accuracy of Harris-Benedict equation using CBW was 83% in overweight subjects (men and women) and
100% in obese women. Whereas accuracy of Mifflin St Jeor equation using CBW was 100% in
overweight subjects (men and women) and 33% in obese women. Thus, use of ABW in both the
predictive equations underestimated RMR of overweight and obese subjects of this study. However,
further studies are needed to assess the accuracy of these equations in subjects with BMI greater than
35kg/m2.

(2005)
Krentisky, J. Adjusted body weight, pro: evidence to support the use of adjusted body weight in
calculating calorie requirements. Nutrition in Clinical Practice. 2005;20(4):468-73. DOI:
10.1177/0115426505020004468.

This article summarizes the results and discusses the limitations of data from studies regarding
calculations for obese hospitalized patients. The use of adjusted body weight is discussed in the context
of what is clinically significant in calculations of energy expenditure and in light of the limitations of current
outcome data.

***Need access to full text to properly evaluate.

3. Hypocaloric feeding outside of the ICU—is it considered good practice in acute care, or only
in ICU?

Justification for Hypocaloric Feeds in the ICU (most recent publications to least recent)

(2019)
Singer, P. et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition.
2019;38:48-79. https://doi.org/10.1016/j.clnu.2018.08.037

If indirect calorimetry is used, isocaloric nutrition rather than hypocaloric nutrition can be progressively
implemented after the early phase of acute illness.

Hypocaloric nutrition (not exceeding 70% of EE) should be administered in the early phase of acute
illness.

After day 3, caloric delivery can be increased up to 80-100% of measured EE.

If predictive equations are used to estimate the energy need, hypocaloric nutrition (below 70% estimated
needs) should be preferred over isocaloric nutrition for the first week of ICU stay.

(2017)
Blaser, A., Berger, M. Early or late feeding after ICU admission? Nutrients. 2017 Dec;9(12):1278. Doi:
10.3390/nu9121278

Early EN should be initiated at a rate below actual EE. Rationale: One small RCT showed increased
mortality with early full EN with elevated targets (30 kcal/kg). In several studies, hypocaloric EN during the
first week of the ICU stay resulted in similar outcomes.

(2016)
McClave, S. et al. Guidelines for the provision and assessment of nutrition support therapy in the adult
critically ill patient: society of critical care medicine (SCCM) and American society for parenteral
and enteral nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition. 2016
Feb;40(2):1259-211. DOI: 10.1177/0148607115621863

Patients requiring PN in the ICU may benefit from a feeding strategy that is hypocaloric (≤20 kcal/kg/d or no more
than 80% of estimated energy needs) but provides adequate protein (≥1.2 g protein/kg/d). This strategy may
optimize the efficacy of PN in the early phases of critical illness by reducing the potential for hyperglycemia and
insulin resistance. In some subsets of patients, avoiding excessive energy intake may reduce infectious morbidity,
duration of mechanical ventilation, and hospital length of stay.

Use of high-protein hypocaloric feeding in hospitalized patients with obesity is associated with at least
equivalent (and possible better) outcomes as use of high-protein eucaloric feeding. In a retrospective
study of 40 obese critically ill surgical and trauma patients, use of high-protein hypocaloric EN was
associated with shorter ICU stay, decreased duration of antibiotics, and fewer days of mechanical
ventilation compared with use of a high-protein eucaloric diet. In 1 of 2 RCTs, use of a parenteral high-
protein hypocaloric diet resulted in similar outcomes (hospital length of stay and mortality) as a high-
protein eucaloric PN regimen. Low intake of protein in combination with a hypocaloric diet may worsen
mortality in obese patients, as was shown in a prospective observational cohort study of adult ICU
patients with class II obesity (BMI, 35–39.9).

Achieving some degree of weight loss may increase insulin sensitivity, facilitate nursing care, and reduce
risk of comorbidities. Providing 60%–70% of caloric requirements promotes steady weight loss.

(2016)
Rugeles, S. et al. High-protein hypocaloric vs normocaloric enteral nutrition in critically ill patients: a
randomized clinical trial. Journal of Critical Care. 2016;35:110-114.
http://dx.doi.org/10.1016/j.jcrc.2016.05.004

Hyperproteic, hypocaloric nutrition did not show different outcomes compared to normocaloric nutrition,
except lower insulin requirements. Hypocaloric nutrition could provide a more physiologic approach with
lower need for care and metabolic impact.

This study compares 1 hypocaloric (12.6 kcal/kg per day), hyperproteic (1.39 g/kg per day) group with a
normocaloric (20.5 kcal/kg per day), hyperproteic (1.42 g/kg per day) group. Both groups were similar in
severity and complexity without differences in Acute Physiology and Chronic Health Evaluation, Results
did not show difference in terms of Sequential Organ Failure Assessment (SOFA) score at 48 and 96
hours, mortality, days on ventilator, or ICU length of stay. However, insulin requirements and percentage
of patients requiring insulin were lower in the hypocaloric group.

Possible Justification for Hypocaloric Feeds Outside of the ICU

(2019)
Zanten, A. et al. Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and
long-term convalescence phases. Critical Care. 2019;23:386. DOI:
https://doi.org/10.1186/s13054-019-2657-5

Based on recent literature and guidelines, gradual progression to caloric and protein targets during the
initial phase of ICU stay is recommended. After this phase, full caloric dose can be provided, preferably
based on indirect calorimetry. Phosphate should be monitored to detect refeeding hypophosphatemia,
and when occurring, caloric restriction should be instituted. During the chronic ICU phase, and after ICU
discharge, higher protein/caloric targets should be provided preferably combined with exercise.

Conclusion: There doesn’t seem to be enough research on the justifications of hypocaloric feeding
outside of the ICU/in acute care. This may be appliciable for those who are overweight/obese but more
studies need to be conducted to determine the efficacy of these practices.