Elsevier

Nutrition

Volume 33, January 2017, Pages 181-186
Nutrition

Applied nutritional investigation
Association between estimated total daily energy expenditure and stage of amyotrophic lateral sclerosis

https://doi.org/10.1016/j.nut.2016.06.007Get rights and content

Highlights

  • Total daily energy expenditure (TDEE) decreased with progression of amyotrophic lateral sclerosis (ALS).

  • Energy intake of patients with ALS patients was not sufficient compared with TDEE.

  • Nutrition support should be started before stage 3 ALS.

  • The Harris–Benedict with a physical activity coefficient proved best for calculating TDEE.

Abstract

Objective

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease, and nutritional status is one of the major prognostic factors of ALS. The aim of this study was to investigate the relationship between total daily energy expenditure (TDEE) and progression of disease in ALS patients, as well as sex differences in TDEE.

Methods

Patients with ALS (N = 370) were diagnosed according to El Escorial criteria and categorized into stage 2, 3, or 4 using a clinical staging system. TDEEs were calculated by summing resting energy expenditure (REE) and physical activity. REE was calculated using equations of Harris–Benedict or Mifflin St. Jeor, and physical activity was calculated using the ALS Functional Rating Scale-Revised, a physical activity coefficient, or adding 30% of REE.

Results

TDEE significantly decreased with progression of ALS stage and did not vary by sex. Actual energy intake was lower than TDEE in patients in all stages and lowest in patients with stage 3 ALS. Comparing TDEEs 1 to 5, TDEE 2 decreased with progression of ALS stage and was similar to the average TDEE.

Conclusions

The present study suggests that TDEE decreases with progression of ALS, and patients consume insufficient energy compared with required intake at all stages, particularly at stage 3, suggesting that nutrition support should be started at least before stage 3. Additionally, among the five equations for TDEE, TDEE 2 could be the best for evaluating the nutritional status of patients with ALS.

Introduction

Amyotrophic lateral sclerosis (ALS), known as Lou Gehrig's disease, is a rare disease characterized by progressive degeneration of lower and upper motor neurons, and the average survival after diagnosis is 3 to 5 y [1]. Despite advances in the understanding of the pathogenic mechanisms of ALS, no satisfactory treatment has been identified [2].

Previous studies found that nutrient intake was associated with risk for ALS, and intake of energy and nutrients decreased during the progression of the disease [3], [4]. Other studies have reported that worsening nutritional status, assessed by body mass index (BMI), with progression of ALS was a major prognostic factor of survival of patients with ALS [5], [6], [7]. Consistently, one study showed that ALS patients with normal BMI had lower risk for death relative to underweight patients [8]. Additionally, mildly obese ALS patients had slower decline in ALS Functional Rating Scale-Revised (ALSFRS-R) score and longer survival time than underweight patients [9]. However, weight loss was commonly observed in patients with ALS, and 70% of them have been reported to consume energy intake lower than the Recommended Daily Allowance [10]. Dysphagia could be the major cause of malnutrition leading to weight loss [11], and patients with ALS also had abnormal energy metabolism through their increasing resting energy expenditure (REE) [12], [13]. Supplementation with a high-calorie diet could prevent weight loss in these patients [14], but overfeeding might create excess production of carbon dioxide, which leads to increased ventilatory efforts. Therefore, the energy expenditure of patients with ALS must be estimated accurately [15].

Results from one study reported that total daily energy expenditure (TDEE), the sum of REE and energy expenditure for physical activity, was 125 kJ/kg daily for patients with ALS, although patients with severe ALS were excluded from the study [16]. In contrast, another study found daily TDEE for ALS patients to be 113 kJ/kg, but only patients with advanced-stage ALS undergoing tracheostomy-positive pressure ventilation were included in the study [17]. Results from the two previous studies suggest that TDEE is lower in patients with severe ALS because body weight, forced vital capacity (FVC), and physical activity decrease with progression of the disease. However, the association between TDEE and progression of ALS has not been studied to our knowledge. In the present study, progression of ALS was categorized by the clinical staging system [18].

To estimate the REE of patients with ALS, previous studies used two equations developed [19], [20]. To our knowledge, although different equations for REE have been developed for male and female participants, there have been no studies to investigate sex differences in REE in patients with ALS. Therefore, the present study sought to investigate the hypothesis that TDEE decreases with progression of ALS, as defined by the clinical staging system, and that there are sex differences in TDEE. In the present study, TDEE was estimated using five equations from previous publications to determine the best TDEE equation for ALS patients, and TDEE was compared with actual energy intake.

Section snippets

Patients

All procedures in this study were conducted according to the guidelines laid out in the Declaration of Helsinki and were approved by the Institutional Review Board of Hanyang University (HYI-14-105-1). Written informed consent was obtained from all patients before enrollment in this study.

Patients (N = 370) were recruited consecutively from the Lou Gehrig Clinic at Hanyang University Seoul Hospital between March 2011 and April 2015. ALS was diagnosed according to El Escorial criteria [21], and

Characteristics of ALS patients

In all, 341 ALS patients were enrolled in this study; 148 were categorized as stage 2, 109 as stage 3, and 84 as stage 4. Moving from stage 2 to 4, K-ALSFRS-R scores, FVC, body weight, BMI, and sun exposure significantly decreased, although the number of patients with bulbar onset increased (Table 2). There were significant sex differences in height, weight, smoking, and drinking status. Male patients had a longer duration of disease and exercised and drank less with each increasing stage;

Discussion

To our knowledge, this is the first study to confirm that TDEE decreased with progression of ALS and to note that there were no sex differences in TDEE. Additionally, actual energy intake was lower than TDEE at all stages, but it was particularly low at stage 3 relative to stages 2 and 4.

Results from a previous study reported that measured daily TDEE was 125 kJ/kg in ALS patients, excluding end-stage patients with ventilation [16]. In another study of end-stage ALS patients who were bedridden

Conclusion

The present study found that TDEE decreased with progression of ALS and that TDEE did not vary by sex, suggesting that energy intake should be prescribed according to clinical stage of ALS. Patients with ALS consumed less than the recommended intake of energy at all stages, but particularly at stage 3, suggesting that nutrition support should be initiated before stage 3. Additionally, the present study suggests that TDEE 2, which calculated REE using the Harris–Benedict equation and the

Acknowledgments

The authors acknowledge the patients and caregivers involved in this study.

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      The most widely used is Harris and Benedict 1919 (HB1919) [9,10,13,14,16]. The Mifflin St. Jeor (Mifflin) formula is also used [17,18]. The difference between mREE and cREE allows for the definition of energy metabolism disorder.

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      There are multiple predictive equations that have also been used to study TDEE and these are less of a burden of subjects than the previous methods (Gerrior, Juan, & Peter, 2006). These equations calculate basal resting metabolism and can calculate TDEE when added to a physical activity coefficient (Gerrior et al., 2006; Lee, Baek, Kim, & Park, 2016; Mafra et al., 2009). A common equation for basal metabolic rate used to find TDEE is the Harris-Benedict equation which accounts for gender, age, height and weight (Frankenfield, Muth, & Rowe, 1998).

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    The present study was supported by a Korean Research Foundation grand funded by the Korean government (015 R1 D1 A1 A09060823) and by a grant from the Korean Health Technology R&D Project, Ministry of Health, Welfare and Family Affairs, Republic of Korea (HI15 C0876). All authors contributed significantly to this paper. PY and LJ wrote the first draft of the study protocol. LJ performed statistical analyses. All authors contributed to interpretation of the results, editing, and to the final text. The authors have no conflicts of interest to declare.

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