The apparent net protein utilization is generated by using the relationship. The obligatory nitrogen loss is roughly equal to 0.1 g/kg of body weight.

 IV.  ESTIMATING ENERGY NEEDS IN ADULTS

      A.  Harris benedict equation (for healthy adults)

          1.  Men: REE = 66 + 13.7W + 5H − 6.8A

          2.  Women: REE = 655 + 9.6W + 1.7H − 4.7A

          3.  Where REE = resting energy expenditure (kcal/d); W = weight (kg); H = height (cm); and A = age (years).

          4.  Validation studies: Original studies conducted on healthy volunteers. Note that for obese individuals (BMI > 29.9), formula may overestimate REE by 5% to 15% if actual weight is used.

      B.  Mifflin–St Jeor equation (for healthy adults)

          1.  Men: REE = 10W + 6.25H − 5A + 5

          2.  Women: REE = 10W + 6.25H − 5A − 161

          3.  Where REE = resting energy expenditure (kcal/d); W = weight (kg); H = height (cm); and A = age (years).

          4.  Validation studies: Equation developed from a sample of obese and nonobese healthy individuals. Some research has indicated that this equation may provide a more accurate estimation of REE than the Harris–Benedict formula in both obese and nonobese individuals, and, therefore, this equation deserves consideration.

      C.  Ireton–Jones ((for acutely ill adults)

          1.  Ventilator-dependent patients: EEE = 1784 − 11A + 5W + 244S + 239T + 804B

          2.  Spontaneously breathing patients: EEE = 629 − 11A + 25W − 609O

          3.  Where EEE = estimated energy expenditure (kcal/d); A = age (y); W = weight (kg); S = sex (male = 1, female = 2); T = diagnosis of trauma (present = 1, absent = 0); B = diagnosis of burn (present = 1, absent = 0); and O = obesity > 30% above ideal body weight from 1959 Metropolitan Life Insurance Tables (present = 1, absent = 0).

          4.  Validation studies: Equation developed from a sample of hospitalized patients including critically ill patients and patients with burns. Recent research has reported that this equation underestimates energy requirements.

      D.  A.S.P.E.N. Energy Expenditure formulas (in calories/kilogram). These formulas have not been validated using evidence-based information. However, they are used as a baseline in clinical practice and adjusted as needed to meet nutrition goals. Using this method, initial calorie goals usually start with 25 kcal/kg and can be adjusted as high as 40 kcal/kg. See table for more specific estimations.

      E.  Protein Needs. Protein intake is crucial during cancer treatment for the maintenance of lean muscle mass as well as the regeneration and repair of cells. Per the Dietary Reference Intakes, healthy individuals are recommended to consume 0.8g/kg protein. Protein needs can increase for cancer patients, especially those undergoing treatment. A catabolic state can increase protein needs to a range of 1.2g/kg to 2.0g/kg per day.

      F.  Assessment of nutritional intake. Individuals can meet daily energy needs through a variety of ways.

          1.  Oral nutrition. The preferred method for providing nutrition for patients who are able to eat is by oral diet, which can be modified according to the physiologic and anatomic constraints of their illness. Nutritional support considerations for individuals with daily energy deficits (e.g., patients with anorexia and resulting weight loss, dysphagia) are listed in Table 42-4.

          2.  Dietary supplements. Nutrients, vitamins, and minerals that are essential for human health as well as a variety of nonessential nutrients such as phytochemicals, hormones, and herbs are used as dietary supplements; however, these should never replace whole foods. The American Cancer Society (ACS) warns against massive doses of any dietary supplement, and recommends supplements that are close to the daily percentage value for most vitamins and minerals. The United States Department of Agriculture (USDA) states that there is no substitute for a well-balanced diet that follows the dietary guidelines for Americans. The daily percentage value (DV) on food labels, formerly known as the recommended daily allowance, is the average daily dietary intake level that is adequate to meet the nutrient requirements of nearly all (97% to 98%) individuals in a specific life stage and gender group. To account for differences in need and ability for absorption, the DV is set considerably higher than the estimated average requirement. Any recommendations for nutritional supplementation at doses higher than twice the DV should be individualized and are dependent on each individual’s dietary and disease status. The Academy of Nutrition and Dietetics recommends getting all the nutrients needed from the diet first and then considering supplementation only if it is adequately researched.

          3.  Enteral feeding. Enteral feeding refers to the provision of nutrients, either to supplement oral intake or as the sole source of nutrition, delivered through a catheter or a tube to the gastrointestinal tract for absorption. Enteral feeding is preferred to parenteral feeding because it preserves the gastrointestinal architecture and prevents bacterial translocation from the gut. Enteral feeding has the advantage of delivering nutrients beyond areas of obstruction, at rates that can maximize nutrient absorption. Nutrients should be administered distal to the ligament of Treitz to avoid complications of aspiration pneumonia and gastric ileus. For short-term feeding, a nasogastric or nasoduodenal tube may be used. If there is a need for long-term enteral support, the preferred method is either a gastrostomy or jejunostomy tube, which can be placed either surgically or endoscopically. Nutritionally complete enteral-feeding formulas as well as specialized modular products to meet specific disease-related nutrient requirements are commercially available. Consult with a dietetics professional to determine the most appropriate formula.

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