According to the American Society for Parenteral and Enteral Nutrition and Academy of Nutrition and Dietetics criteria, the diagnosis of malnutrition includes an evaluation of muscle and fat. The role of inflammation not only enhances the catabolism of muscle and fat loss but also interferes with anabolism. Dietitians and other nutrition professionals need to understand techniques to appropriately identify losses of muscle and fat to incorporate them into a malnutrition diagnosis. Proper training is imperative to correctly identify muscle and fat wasting in a consistent and reliable manner. Nutrition clinicians should begin incorporating these practices into patient assessments and care plans. The application of these techniques and assessment tools is challenging and continues to be a work in progress. Various scenarios do not allow for clearly defined methods that would lead to a reliable conclusion for diagnosing malnutrition indicating the need for further research.

Patients with cirrhosis have increased gluconeogenesis and fatty acid oxidation that may contribute to a low respiratory quotient (RQ), and this may be linked to sarcopenia and metabolic decompensation when these patients are hospitalized. Therefore, we conducted a prospective study to measure RQ and its impact on skeletal muscle mass, survival, and related complications in hospitalized cirrhotic patients. Fasting RQ and resting energy expenditure (REE) were determined by indirect calorimetry in cirrhotic patients (n = 25), and age, sex, and weight-matched healthy controls (n = 25). Abdominal muscle area was quantified by computed tomography scanning. In cirrhotic patients we also examined the impact of RQ on mortality, repeat hospitalizations, and liver transplantation. Mean RQ in patients with cirrhosis (0.63 ± 0.05) was significantly lower (P < 0.0001) than healthy matched controls (0.84 ± 0.06). Psoas muscle area in cirrhosis (24.0 ± 6.6 cm(2)) was significantly (P < 0.001) lower than in controls (35.9 ± 9.5 cm(2)). RQ correlated with the reduction in psoas muscle area (r(2) = 0.41; P = 0.01). However, in patients with cirrhosis a reduced RQ did not predict short-term survival or risk of developing complications. When REE was normalized to psoas area, energy expenditure was significantly higher (P < 0.001) in patients with cirrhosis (66.7 ± 17.8 kcal/cm(2)) compared with controls (47.7 ± 7.9 kcal/cm(2)). We conclude that hospitalized patients with cirrhosis have RQs well below the traditional lowest physiological value of 0.69, and this metabolic state is accompanied by reduced skeletal muscle area. Although low RQ does not predict short-term mortality in these patients, it may reflect a decompensated metabolic state that requires careful nutritional management with appropriate consideration for preservation of skeletal muscle mass.

Background Indirect calorimetry is a noninvasive and reliable means of determining resting metabolic rate in humans. Barriers to obtaining an accurate measure of resting metabolic rate in hospitalized patients include the expense and the requirement of technical expertise for maintenance. Methods A literature search on hand-held calorimeters was conducted using PubMed and OVID. The search resulted in a total of 54 published articles; 23 of these specifically are about hand-held calorimeter devices. Results Results from a hand-held calorimeter were similar to those obtained from metabolic cart studies. The Douglas bag method compared to the MedGem indicated a significant agreement with a p=0.286. The hand-held device compared to metabolic carts in 9 studies with mixed results. The predictive equations (Harris-Benedict, Mifflin St. Joer and FAO/WHO equations) were found to over and underestimate RMR compared to the MedGem. The Harris-Benedict was found to overestimate the RMR by 3-11%, the Mifflin St Joer equation overestimated the RMR by 1% and the FAO/WHO equation overestimated RMR by 12%. Conclusion The present study examines the validity and reliability of hand-held calorimeters for measuring resting energy expenditure based on published literature. Hand-held calorimeters are more accurate than predictive equations based on gender, age and ethnicity for determining resting metabolic rate and are therefore a viable alternative for clinical evaluation of the hospitalized patient.

Background Nutrition management of cirrhosis in hospitalized patients is overlooked despite the clinical significance of sarcopenia or loss of muscle mass in cirrhosis. Determining optimal nutrition requirement needs precise measurement of resting energy expenditure (REE) in the cirrhotic patient. Predictive equations are not accurate, and the metabolic cart is expensive and cumbersome. The authors therefore performed a prospective study to examine the feasibility and accuracy of a handheld respiratory calorimeter (HHRC) in quantifying the REE in hospitalized cirrhotic patients not in the intensive care unit. Materials and Methods The study was done in 2 phases: in the first phase, the REE of 24 consecutive healthy volunteers was measured using an HHRC in different positions. The objective of this phase was to identify the impact of body and arm position on measured REE. Subsequently, in the second phase of the study, REE was measured using the HHRC and the metabolic cart in 25 consecutive well-characterized, hospitalized cirrhotic patients. The degree of concordance was calculated. Results Body position and arm position did not significantly affect the measured REE using HHRC. In patients with cirrhosis, the mean measured REE (kcal/d) using the HHRC was 1453.2 ± 319.3 in the hospital room, 1525.6 ± 305.2 in a quiet environment, and 1553.7 ± 270.6 with the metabolic cart (P > .1). Predicted REE using 2 widely used equations did not correlate either with each other or with the measured REE. Conclusions HHRC is a valid, feasible, and rapid method to determine optimal caloric needs in hospitalized cirrhotic patients.

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