Nutrition 22 (2006) 345–349
www.elsevier.com/locate/nut
Applied nutritional investigation
Recommended and actual calorie intake of intensive care unit patients
in a private tertiary care hospital in the Philippines
Maria Nenita Umali, R.N.D., M.S.N., Luisito O. Llido, M.D.,* Eliza Mei P. Francisco, M.D.,
Marianna S. Sioson, M.D., Edmon C. Gutierrez, R.Ph., Edelina G. Navarrette, R.N.D., and
Michael John Encarnacion, M.D.
Nutrition Support Services, St. Luke’s Medical Center, Manila, Philippines
Manuscript received January 31, 2005; accepted September 5, 2005.
Abstract
Objectives: This study compared the computed nutrient requirements of geriatric patients under
critical care with their actual intake within the first 3 d after admission to the intensive care unit
(ICU) and determined the percentage of patients who achieved adequate intake.
Methods: Fifty-eight geriatric patients who were admitted to the ICU from September to December
2002 were prospectively enrolled. Recommended and actual calorie intakes per patient were
recorded and mean amount of carbohydrate, protein, and fat consumed were calculated. Student’s
t test was used to compare actual with recommended nutrient intakes.
Results: Actual in relation to recommended nutrient intake was inadequate (41.5% on day 1 to
71.7% on day 3 for calories and 21.1% on day 1 to 24.3% on day 3 for protein, P ⬍ 0.001).
Carbohydrate intake was low (falling from 61.9% on day 1 to 39.8% on day 3, P ⬍ 0.001) and fat
intake was also low (increasing from 29.4% to 37.9% on day 3, P ⬍ 0.001). The percentage of
patients who achieved adequate intake was 51.2% on day 1 and increased to 73.2% on day 3.
Conclusions: The intake of geriatric patients in the ICU is low, with differences in actual and
recommended intakes. Delivering what is recommended is still a goal to be realized in the ICU
setting. © 2006 Elsevier Inc. All rights reserved.
Keywords:
Recommended calorie intake; Actual calorie intake; Intensive care unit; Nutritional support; Enteral nutrition;
Parenteral nutrition; Body mass index; Geriatric
Introduction
Malnutrition is a common occurrence in the hospital and
adds significantly to length of hospital stay and health care
costs. The prevalence of malnutrition in hospitalized patients has been documented in several studies [1–7]. Multiple surveys have shown that 50% of hospitalized patients
are malnourished and up to 12% are severely malnourished
[4 – 8]. Malnutrition is associated with higher morbidity and
mortality in hospitalized patients and the group with the
highest risk of developing these complications is in the
intensive care unit (ICU), particularly geriatric patients.
Recent consensus data have recommended that appropriate
calorie intake should be provided to critically ill patients as
* Corresponding author. Fax: ⫹632-723-0101, loc. 4710.
E-mail address: [email protected](L.O. Llido).
0899-9007/06/$ – see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.nut.2005.09.002
a major component of therapy [9]. Feeding geriatric patients
under critical care will adequately improve their capacity
for healing and recovery; hence, this goal has been considered a priority in intensive care management 48 to 72 h after
admission [10]. Surveys of nutritional support have reported
discrepancies between prescribed intake and actual delivery of
calories for patients in the ICU [11,12]. A prospective study of
five ICUs in the United Kingdom has reported that the prescription of optimal energy requirements ranged from 76% to
100% [13]. Another study of patients in the ICU who used
enteral nutrition showed that only 65.6% of daily goal requirement was ordered by the physician [14]. Because the issue of
adequacy of intake of patients in the ICU has not yet been
evaluated in this center, a survey of patients’ calorie requirements and actual intake was undertaken, with a focus on the
geriatric population. This study also evaluated the standards of
nutritional care of the medical staff.
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M.N. Umali et al. / Nutrition 22 (2006) 345–349
Materials and methods
This descriptive study was conducted in the adult intensive care and critical care units of St. Luke’s Medical Center
(Manila, Philippines), a private tertiary care hospital, from
September to December 2002. Fifty-eight patients were
prospectively enrolled in the study if they met the following
inclusion criteria: age 60 y and older and use of tube feeding
and/or parenteral nutrition. Exclusion criteria were an age
younger than 60 y and oral feeding or diets that were shifted
to oral within the 3-d study period. Gathered data consisted
of age, sex, body mass index (BMI), type of nutrition,
computed total caloric requirement, total protein requirement, and actual intake or daily calorie counts for 3 consecutive days. Total calorie requirement per day was computed by using two methods. For calorie requirements on
day in the ICU, the “short method” was used, which is done
by multiplying a patient’s actual body weight in kilograms
by 20 kcal/kg. Calorie requirement on day 2 is computed by
using the short method, but this time multiplying the weight
in kilograms by 25 kcal/kg. Calorie requirement for day 3 is
computed by using the Harris-Benedict equation multiplied
by a factor of 1.3. Total protein requirement is computed by
multiplying actual body weight in kilogram by a factor that
depends on the disease state (0.8 to 1.5 g/kg of actual body
weight). Computation of calorie requirement for obese patients (BMI ⬎ 30 kg/m2) was based on their ideal body
weight. Data were recorded daily on nutrient monitoring
sheets. The study period of 3 consecutive days follows the
hospital nutritional support services guideline that patients
who are at high risk of developing malnutrition or in critical
care should receive adequate intake within 72 h of admission in the ICU. Intake is considered adequate when 75% of
the computed requirement is achieved [15]. Demographic
data were tabulated and percentage distribution was determined for characteristics, illnesses, and diet prescription of
all patients. Nutritional status based on BMI used the following values as recommended by the World Health Organization: BMI below 18.5 kg/m2 (underweight), 25 to 30
kg/m2 (overweight), and above 30 kg/m2 (obese) [16]. Mean
amounts of carbohydrate, protein, and fat intake were also
calculated. Student’s t test (paired samples t test) was used
to compare actual with recommended nutrient intakes of
patients, with the level of statistical significance set at P ⬍
0.05. Statistical analysis was performed with SPSS 11
(SPSS, Inc., Chicago, IL, USA).
Results
Most patients were 60 to 79 y old (74.2%), with equal
distributions between men and women. Most patients
(58.6%) had normal BMI levels; among malnourished patients, 8.6% were underweight, 24.1% were overweight, and
8.6% were obese. Most patients (56.9%) were admitted due
to medical conditions and 43.1% were admitted for medical
Table 1
Baseline demographics of patients*
Total patients
Male
Female
Age range (y)
60–69
70–79
80–89
ⱖ90
Nutritional status (BMI)
Underweight (⬍18.5 kg/m2)
Normal (18.5–24.9 kg/m2)
Overweight (25–29.9 kg/m2)
Obese (ⱖ30 kg/m2)
Type of management
Medical
Medical and surgical
58
29 (50%)
29 (50%)
23 (39.7%)
20 (34.5%)
11 (19%)
4 (6.9%)
5 (8.6%)
34 (58.6%)
14 (24.1%)
5 (8.6%)
33 (56.9%)
25 (43.1%)
BMI, body mass index
* Values are numbers of patients (percentages).
and surgical conditions. The frequency and percentage distribution of patients with respect to sex, age, BMI, and type
of illness are listed in Table 1. Most patients (43.1%) received a combination of enteral and parenteral nutrition on
day 1; by day 3, there was a shift to entirely enteral nutritional support (37.9%). No nutritional support was given to
5.2% of patients throughout the study period (Table 2).
Comparative analyses of actual and recommended calorie intakes showed a mean actual intake of 491.33 kcal
compared with a mean computed intake of 1183.83 kcal on
day 1 in the ICU (mean difference 688.2 kcal, P ⬍ 0.001,
42.01% of goal reached). On day 3, mean actual calorie
intake was higher at 1187.12 kcal compared with the mean
computed intake of 1656.03 kcal (mean difference 477.14
kcal, P ⬍ 0.001, 71.4% of goal reached; Table 3). Comparison of actual with recommended protein intake showed
mean actual protein intake to be 9.96 g on day 1 compared
with a mean computed protein intake of 47.12 g (mean
difference 37.17 g, P ⬍ 0.001, 21.4% of goal reached). On
day 3, mean actual protein intake increased to 14.13 g
compared with a mean computed protein intake of 58.9 g
(mean difference 44.59 g, P ⬍ 0.001, 24.3% of goal
reached; Table 3). Mean actual carbohydrate intake on day
1 was 73.57 g compared with a mean computed intake of
118.7 g (mean difference 45.12 g, P ⬍ 0.001, 61.9% goal
Table 2
Percentage distribution of patients according to type of nutrition
received*
Nutrition Type
Day 1
Day 2
Day 3
Enteral nutrition
Parenteral nutrition
Intravenous dextrose
Mixed
No nutritional intake
10 (17.2)
2 (3.5)
12 (12.7)
25 (43.1)
9 (15.5)
18 (31)
3 (5.2)
5 (8.6)
27 (46.6)
3 (5.2)
22 (37.9)
9 (15.5)
8 (13.8)
16 (27.6)
3 (5.2)
* Values are numbers of patients (percentages).
M.N. Umali et al. / Nutrition 22 (2006) 345–349
347
Table 3
Actual versus recommended intake of nutrients
Nutrition given
Mean intake
ICU day 1
ICU day 2
ICU day 3
Calorie (kcal/d)
Actual
Recommended
Difference†
Percent goal reached
Actual
Recommended
Difference
Percent goal reached
Actual
Recommended
Difference
Percent goal reached
Actual
Recommended
Difference
Percent goal reached
491.33
1183.33
⫺692.5*
41.5‡
9.96
47.12
⫺37.17*
21.14‡
73.57
118.7
⫺45.12*
61.9‡
15.51
52.8
⫺37.3*
29.4‡
926.55
1479.78
⫺553.23*
62.6‡
13.22
58.9
⫺45.68*
22.44‡
69.92
148.4
⫺78.48*
47.1‡
26.84
65.9
⫺39.1*
40.7‡
1187.12
1656.03
⫺468.91*
71.7‡
14.31
58.9
⫺44.59*
24.3‡
68.21
171.2
⫺102.9*
39.8‡
28.82
76.1
⫺47.3*
37.9‡
Protein (g/d)
Carbohydrate (g/d)
Fat (g/d)
* P ⬍ 0.001 (paired samples t test).
†
Difference ⫽ actual intake ⫺ recommended intake.
‡
Percent ⫽ (actual intake/recommended intake) ⫻ 100.
reached). On day 3, mean actual carbohydrate intake decreased to 68.21 g; compared with a mean computed intake
of 171.2 g, a mean difference of 102.9 g was seen (P ⬍
0.001, 39.8% goal reached; Table 3). For fat intake, mean
actual intake on day 1 was 15.51 g versus a mean computed
intake of 52.8 g, for a mean difference of 45.67 g (P ⬍
0.001, 29.4% goal reached). Mean actual fat intake on day
3 increased to 28.82 g versus a mean computed intake of
76.1 g, with a mean difference of 47.3 g (P ⬍ 0.001, 37.9%
goal reached; Table 3). Mean calorie and protein intakes did
not reach the 75% calorie cutoff for adequacy even up to
day 3 (Figs. 1 and 2), indicating that none of the target
nutritional goals was reached within the first 3 d in the ICU.
The percentage of patients who reached an adequate calorie
intake (75% of computed intake) increased from 51.2% on day
1 in the ICU to 73.2% on day 3. Only 6.7% of patients
achieved adequate protein intake on day 1 in the ICU, but this
decreased further to 2.2% from days 2 to 3 (Table 4). Underweight patients received higher nutrient intakes compared with
obese patients (33.16 versus 16.75 kcal/kg on day 1 and 33.4
versus 20.3 kcal/kg on day 3; Table 5).
al. [12], digestive intolerance, airway management, and
diagnostic procedures contribute to interruptions in feeding,
which result in low actual intake. This observation should
alert the medical staff of the need for closer monitoring and
follow-up of such patients, especially of their nutrient intakes.
Calorie and nutrient intakes of the patients in this study
were insufficient and, although a gradual increase over the
next 2 d was observed, the medical staff was still unable to
achieve 100% adequacy of the total calorie requirement in
all patients (only 73.2% of patients achieved adequate calorie intake on day 3). The total protein requirement was also
not reached (2.2% of patients with adequate protein intake
on day 3), suggesting that most patients are generally un-
Discussion
The study focused on the first 3 d of ICU admission
based on observations that outcome can be improved if
nutritional support is instituted early and adequately
[10,17]. The patients chosen for the study were from a
geriatric age group (60 to 90 y old) in which significant
age-related complications and hindrances to feeding are
commonly encountered because these patients often require
more laboratory and therapeutic procedures that may have
effects on their nutritional status. According to De Jonghe et
Fig. 1. Recommended (black bars) versus actual (white bars) caloric intake
(*P ⬍ 0.001). ICU, intensive care unit.
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M.N. Umali et al. / Nutrition 22 (2006) 345–349
Table 5
Calorie intake according to BMI class*
Nutritional status (BMI)
Day 1
Day 2
Day 3
Underweight (n ⫽ 2)
Normal (n ⫽ 28)
Overweight (n ⫽ 9)
Obese (n ⫽ 2)
33
17.3
23.1
16.7
24.1
26.2
24.1
18.3
33.4
25.9
25.7
20.3
BMI, body mass index
* Values are mean kilocalories per kilogram of body weight per day.
Fig. 2. Recommended (black bars) versus actual (white bars) protein intake
(*P ⬍ 0.001). ICU, intensive care unit.
derfed by day 3 of confinement. We also included the
number of patients who were not given any form of nutrition even on day 3 (5.2%) to emphasize the point that
non-feeding can occur in these patients even on day 3.
These results add to the increasing number of data documenting the inadequate actual intake of patients in the ICU
[9,11–14]. This further emphasizes that, despite consensus
and awareness of its positive effect on all patients under
critical care, the practice in achieving adequate nutrient
delivery leaves a lot to be desired.
Many reasons have been suggested to cause this problem, such as digestive intolerance, airway management, and
diagnostic procedures, which interrupt continuity of feeding. A low prescription rate of nutritional support was also
linked to administration of vasoactive drugs, central venous
catheterization, and institution of extrarenal replacement
[12]. These factors have also been observed in the ICU
setup of our institution, but, despite the existence of guidelines to address these problems, these were not enough to
ensure the expected adequate delivery of the prescribed diet.
This reflects the lack of implementation of policies on the
part of the medical staff in the nutritional management of
patients under critical care. A major factor would be the
presence of less experienced critical care nurses manning
the ICU due to a rapid turnover of nurses who leave for
work abroad, resulting in delays in the notification process
to the nutrition team or the attending physician. The next
Table 4
Patients (percentages) who achieved adequate calorie and protein intake
Nutrient intake*
Day 1
Day 2
Day 3
Adequate calorie
Adequate protein
21/41 (51.2%)
3/45 (6.7%)
29/41 (70.7%)
1/45 (2.2%)
30/41 (73.2%)
1/45 (2.2%)
* Greater than 75% intake is considered adequate.
factor would be a lack of intensive care specialists who are
available to train and supervise the residents and fellows
who are assigned in the ICU, thus having some staff on duty
who are not fully aware of the need for immediate adjustments of nutrient requirements or who resume feeding when
the period of “nothing per oral” has lapsed. This lack of
close coordination among the different personnel in the
notification and update of status whenever a patient is
placed on non-oral status contributes to a delay in onset or
resumption of feeding to the patient. The need for awareness
of some medical staff about the value of prompt nutritional
support delivery in the critically ill is still prevalent, which
may be a factor as to why some patients were still on
non-oral status even on day 3.
It may seem that nutrient intake improved with an increasing number of patients reaching at least 75% of their
total caloric requirement by day 3, but only 73.2% of patients successfully received sufficient nutrition by the end of
the 3-d study period (Table 4). The different caregivers of
critical care nutritional support must be informed about this
finding. Taking into consideration the aforementioned
causes of delay in the delivery of nutritional support and
correlating these with actual delivery would help in the
development of more improved protocols or guidelines that
might result in prompt action that would improve nutrient
delivery. The main focus would center on making adjustments in the manner of nutritional delivery and requiring
more frequent and closer intake monitoring by nurses, dietitians, and physicians.
Combined types of nutrition delivery were given to most
patients at the start of the study, but there was a trend to
simplify feeding by administering only enteral nutrition by
day 3. Enteral nutrition is preferred over the other forms
because of its affordability [18], fewer complications [19],
and its ability to preserve gut structure function [20,21].
This attempt to simplify feeding may have also contributed
to the inadequacy problem. Therefore, it is necessary to
have strict daily calorie counting to initiate adjustments in
feeding routes (combined versus total parenteral nutrition)
early in treatment. There is a tendency to be more aggressive in achieving nutritional goals in underweight patients,
whereas feeding progress is slower among obese patients
(Table 5). Thus, the latter group had comparatively less
intake than the former. This type of practice bias may have
M.N. Umali et al. / Nutrition 22 (2006) 345–349
later repercussions on treatment outcomes and length of
hospital stay in the obese group.
This study has underscored the importance of closely
monitoring the nutrient intake of critically ill patients and
initiating the prescribed feeding as soon as possible. This
practice is recommended to be part of the critical care
nutritional support protocol to decrease malnutrition during
confinement and thus hasten recuperation of patients. Emphasis should be placed on aggressive monitoring of intake
to ensure that each patient receives what is being prescribed
and that the medical staff is notified accordingly. As a final
recommendation, updates, continued education, and training in nutritional support practice for critically ill patients
should be a regular activity for all members of the medical
and support staff of the hospital.
Acknowledgments
The authors are indebted to members of the Nutrition
Support Team of St. Luke’s Medical Center for help in
gathering data and computation of caloric intake and to the
patients and their families for participating in this scientific
investigation.
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