Resting energy expenditure, calorie and protein consumption in critically ill patients: a retrospective cohort study
Open accessAbstract
BACKGROUND: Intense debate exists regarding the optimal energy and protein intake for intensive care unit (ICU) patients. However, most studies use predictive equations, demonstrated to be inaccurate to target energy intake. We sought to examine the outcome of a large cohort of ICU patients in relation to the percent of administered calories divided by resting energy expenditure (% AdCal/REE) obtained by indirect calorimetry (IC) and to protein intake. METHODS: Included patients were hospitalized from 2003 to 2015 at a 16-bed ICU at a university affiliated, tertiary care hospital, and had IC measurement to assess caloric targets. Data were drawn from a computerized system and included the % AdCal/REE and protein intake and other variables. A Cox proportional hazards model for 60-day mortality was used, with the % AdCal/REE modeled to accommodate non-linearity. Length of stay (LOS) and length of ventilation (LOV) were also assessed. RESULTS: A total of 1171 patients were included. The % AdCal/REE had a significant non-linear (p < 0.01) association with mortality after adjusting for other variables (p < 0.01). Increasing the percentage from zero to 70 % resulted in a hazard ratio (HR) of 0.98 (CI 0.97-0.99) pointing to reduced mortality, while increases above 70 % suggested an increase in mortality with a HR of 1.01 (CI 1.01-1.02). Increasing protein intake was also associated with decreased mortality (HR 0.99, CI 0.98-0.99, p = 0.02). An AdCal/REE >70 % was associated with an increased LOS and LOV. CONCLUSIONS: The findings of this study suggest that both underfeeding and overfeeding appear to be harmful to critically ill patients, such that achieving an Adcal/REE of 70 % had a survival advantage. A higher caloric intake may also be associated with harm in the form of increased LOS and LOV. The optimal way to define caloric goals therefore requires an exact estimate, which is ideally performed using indirect calorimetry. These findings may provide a basis for future randomized controlled trials comparing specific nutritional regimens based on indirect calorimetry measurements.
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Zusman et al. found that both under- and overnutrition were harmful.
“This study corroborated that both under- and overnutrition were harmful.”
From Nutrition in Sepsis: A Bench-to-Bedside Review. (2020) · cites this paper as [21]
The Conclusions say the findings suggest that underfeeding and overfeeding appear harmful in mechanically ventilated, critically ill patients. The claim states harm as a fact, whereas the paper describes an observational association and says higher caloric intake may be associated with harm. (LLM, conf=0.85)
Experimental — accuracy not yet measuredThe EAT-ICU study did not find any harm or advantage in terms of morbidity, long term function or mortality when associating supplemental PN with enteral feeding from the early stage of admission to reach a target defined by indirect calorimetry.
“Finally the EAT-ICU study (129) associating supplemental PN with enteral feeding from the early stage of admission in order to reach a target defined by indirect calorimetry, did not find any harm or advantage in terms of morbidity, long term function or mortality.”
From ESPEN guideline on clinical nutrition in the intensive care unit. (2019) · cites this paper as [129]
Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredA larger database analysis suggested that energy intake is associated with significantly improved survival when it is close to measured EE or between 70 and 100% of the repeatedly measured resting EE.
“A larger database analysis suggested that energy intake is associated with significantly improved survival when it is close to measured EE [55] or between 70 and 100% of the repeatedly measured resting EE [56].”
From ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit (2023) · cites this paper as [56]
The Results report the lowest 60-day mortality at 70% of administered calories to measured resting energy expenditure (REE). They also report increasing mortality as intake rises above 70%, so the cited paper does not support improved survival across the full 70–100% range. The Discussion says many patients had repeated measurements, not that REE was repeatedly measured for every patient. (LLM, conf=0.88)
Experimental — accuracy not yet measuredUndernutrition or over-nutrition is deleterious to outcome according to large observational studies.
“Undernutrition or over-nutrition is deleterious to outcome according to these large observational studies.”
From ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit (2023) · cites this paper as [56]
The Conclusions say this observational study suggests that both underfeeding and overfeeding appear harmful in mechanically ventilated, critically ill patients. The claim states harm more definitively and treats undernutrition broadly, whereas the Discussion reports that patients receiving 70% of target calories fared better than those receiving 100%. (LLM, conf=0.85)
Experimental — accuracy not yet measuredThe analysis of a large data base including 1171 patients with indirect calorimetry data confirmed that under- and overfeeding were both deleterious, and that the optimal amount appeared to be between 70 and 100% of measured EE.
“Recently the analysis of a large data base including 1171 patients with indirect calorimetry data [56] confirmed that under-and overfeeding were both deleterious, and that the optimal amount appeared to be between 70 and 100% of measured EE.”
From ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit (2023) · cites this paper as [56]
The Abstract Results report 1,171 patients, and the Results describe a U-shaped association between calorie intake and 60-day mortality. But the lowest observed mortality was at 70% of measured resting energy expenditure, not throughout a 70–100% range. The Discussion also cautions that this observational study cannot establish that under- or overfeeding caused harm, so 'confirmed' is too strong. (LLM, conf=0.88)
Experimental — accuracy not yet measured
An AdCal/REE above 70% suggested an increase in mortality and was associated with increased duration of ventilation and length of ICU stay.
“An AdCal/REE above 70% suggested an increase in mortality and was associated with increased duration of ventilation and length of ICU stay [21].”
From Nutrition in Sepsis: A Bench-to-Bedside Review. (2020) · cites this paper as [21]
Calorie and protein dosing are correlated with mortality.
“calorie and protein dosing are correlated with mortality [21]”
From Nutrition in Sepsis: A Bench-to-Bedside Review. (2020) · cites this paper as [21]
The EAT-ICU study compared a goal-directed group receiving EE measured with indirect calorimetry as a caloric target within 24 hours to standard therapy; no advantages or harm were observed in functional outcome, morbidity, or mortality.
“The recent EAT-ICU study compared the goal-directed group, receiving the EE measured with indirect calorimetry as a caloric target to reach within 24 hours to patients receiving standard therapy.The study group also received protein according to urinary nitrogen loss.No advantages or harm was observed in terms of functional outcome, morbidity, or mortality in this RCT (129).”
From ESPEN guideline on clinical nutrition in the intensive care unit. (2019) · cites this paper as [129]
The Methods describe a retrospective ICU cohort, not the EAT-ICU randomized trial. The Discussion addresses other nutrition studies, but our copy provides no account of EAT-ICU’s treatment groups, 24-hour target, urinary-nitrogen protocol, or outcomes (searched: EAT-ICU, functional outcome, urinary nitrogen loss, and 24 hours). Page numbers were not available in our copy. (LLM, conf=0.78)
Experimental — accuracy not yet measuredThe EAT ICU study compared high protein intake administered according to nitrogen excretion from day one to standard administration and did not find any difference in six minute walk test or other morbidity/mortality parameters.
“The EAT ICU study (129) compared high protein intake administered according to nitrogen excretion from day one to standard administration and did not find any difference in six minute walk test (primary objective) or other parameters related to morbidity or mortality.”
From ESPEN guideline on clinical nutrition in the intensive care unit. (2019) · cites this paper as [129]
The Methods describe a retrospective cohort assessing calorie and protein intake, and the Results report associations with 60-day mortality (no page numbers supplied). Searches for EAT ICU, nitrogen excretion, and the six-minute walk test found no passage describing that trial or its outcomes. This paper’s mortality findings cannot establish whether the EAT ICU groups differed. (LLM, conf=0.78)
Experimental — accuracy not yet measuredA U-shaped relationship exists between caloric supply and mortality, with best survival when around 70% REE was provided.
“Their results indicated a U-shaped relationship between caloric supply and mortality, with the best survival when around 70% REE was provided.”
From Energy delivery guided by indirect calorimetry in critically ill patients: a systematic review and meta-analysis (2021) · cites this paper as [1]
Caloric requirements in ICU patients may change during hospitalization, irregularly and unpredictably due to the phase of critical illness, nutritional support, analgesia, neuromuscular blockade, sedation, early rehabilitation, and other unknown factors.
“On the other hands, caloric requirements in ICU patients may change during hospitalization. These changes may be irregular and unpredicted due to the phase of critical illness, nutritional support, analgesia, neuromuscular blockade, sedation, early rehabilitation, and other unknown factors [1].”
From Energy delivery guided by indirect calorimetry in critically ill patients: a systematic review and meta-analysis (2021) · cites this paper as [1]
Too high or too low energy supply is associated with a worse prognosis.
“Of note, researches have demonstrated that too high or too low energy supply is associated with a worse prognosis [1].”
From Energy delivery guided by indirect calorimetry in critically ill patients: a systematic review and meta-analysis (2021) · cites this paper as [1]
Avoiding underfeeding and overfeeding is an important factor directly related to nutritional support in critically ill patients.
“It has been demonstrated that avoiding underfeeding and overfeeding is an important factor directly related to nutritional support in critically ill patients [1].”
From Energy delivery guided by indirect calorimetry in critically ill patients: a systematic review and meta-analysis (2021) · cites this paper as [1]
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- Authors
- Zusman, O., Theilla, M., Cohen, J., Kagan, I., Bendavid, I., & Singer, P.
- Affiliations
- Rabin Medical Center (IL)
- Tel Aviv University (IL)
- Corresponding author
- Zusman, Oren
- Venue
- Critical Care
- Published
- 2016-11-10
- Volume
- 20
- Issue
- 1
- Pages
- 367-367
- ISSN
- 1364-8535 (ISSN-L)
- PMC
- PMC5105237
- OpenAlex
- W2554731092
- Cited by
- 421
- References
- 16
- Citations by year
- 2026: 37 · 2025: 37 · 2024: 56 · 2023: 57 · 2022: 50 · 2021: 49 · 2020: 50 · 2019: 34 · 2018: 31 · 2017: 19
- FWCI
- 29.31
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- Critical Care (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Clinical Nutrition and Gastroenterology
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hyperglycemia and glycemic control in critically ill and hospitalized patients
- Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
- Keywords
- resting energy expenditure, indirect calorimetry, energy intake, protein intake, critically ill patients, intensive care nutrition, 60-day mortality, length of hospital stay, mechanical ventilation duration, underfeeding, overfeeding
- MeSH terms
- Adult, Aged, Aged, 80 and over, Energy Intake, Dietary Proteins, Energy Metabolism, Female, Humans, Intensive Care Units, Male, Middle Aged, Nutritional Requirements, Retrospective Studies, Cohort Studies, Critical Illness
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