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Resting Energy Expenditure

Predicting Velocity of Weight Loss

in

Moderate Obesity

KONSTANTIN N. PAVLOU, SC.D.

MARTHA A. HOEFER, B.A.

GEORGE L. BLACKBURN, M.D., PH.D.

The predicted resting metabolic rate (pRMR), as is estimated by the Harris-Benedict equation (HBE), was compared with the actual resting metabolic rate (mRMR), as assessed by indirect calorimetry, in 31 moderately obese (X above ideal body weight = 44 ± 2.8%) male subjects (X age = 48 ± 4.5 years; X weight = 107.3 ± 17.1 kg; X% fat = 34 ± 3.9). Measured resting metabolic rate (mRMR) (1,942 ± 293 kcal/day) was found to be significantly (p < 0.001) lower than pRMR (2,108 ± 270 kcal/ day), but significantly higher (p < 0.001) than pRMR (1,636 ± 133 kcal/day), if ideal body weight was used in the HBE formula. Individual variation of the mRMR and pRMR ranged from 65-105% and 95-155% of the expected normal population values, respectively. The findings suggest that if the reduced daily caloric needs observed are added to the metabolic suppression occurring during dietary restriction, it might explain why many obese individuals experience difficulties in maintaining predicted rates of weight loss. An equation was derived to predict RMR in moderately obese male patients.

From the Nutrition/Metabolism Laboratory, Cancer Research Institute, New England Deaconess Hospital, Harvard Medical School, and Nutritional Management, Inc., Boston, Massachusetts

O

BESITY is considered one of the most common

medical disorders.' Current estimates from the National Center for Health Statistics cite the incidence of obesity (defined as > 130% of ideal body weight) at 14% for males and 27% for females.2 Its treatment is credited with a concomitant reduction in the incidence of such life-threatening conditions as coronary heart disease, hypertension, and diabetes.3'4 The various treatment techniques available5 attempt to create an energy imbalance in which daily caloric expenditure exceeds the prescribed kilojoule intake. To achieve this, standard predictor equations are used to estimate resting energy needs6 with an additional 20% for daily physical activity. During the initial weeks of dietary treatment, almost every patient demonstrates a psychologically gratifying

rate of weight loss. Some of this weight loss is fat due to kilojoule deficit; the remainder is due to losses in protein and water.7 The inability of many obese patients to sustain a predetermined rate of weight loss, especially as they near their ideal body weight goal, is well known to clinicians. A recently published study attempted to explain this discrepancy.8 These researchers report that morbidly obese subjects preparing for gastric bypass surgery demonstrate a lower resting metabolic rate (RMR) than is estimated using the Harris-Benedict Equation (HBE). However, they were unable to explain a significant amount of the variance in RMR attributable to the independent variables and therefore could not propose a clinically useful equation to predict more accurately the daily kilojoule needs for the obese. In an effort to develop a new standard predictive equation of the RMR of the obese patients, we compared the predicted resting metabolic rate (pRMR), as is estimated by the HBE, with measured resting metabolic rate (mRMR), as assessed by indirect calorimetry in moderately obese male subjects.

Methods

Reprint requests: Dr. Pavlou, Cancer Research Institute, 194 Pilgrim Road, Boston, MA 02215. Submitted for publication: September 16, 1985.

Thirty-one moderately obese male subjects participated in a study of weight loss resulting from a 4180 kj (1000 kcal) balanced deficit diet and an aerobic exercise program. Analysis of the baseline RMR measurements of these men prior to dietary intervention is presented here. They ranged from 30 to 60 years ofage (X age = 48 ± 8.5 years), and 21 to 70 (X = 44 ± 15.6)% above ideal body

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RESTING ENERGY EXPENDITURE IN MODERATE OBESITY

137
LBM (kg)
FM %

TABLE 1. Anthropometric Characteristics*
N Age (years)

Height (cm)
178.1 ± 5.1
=

Weight
(kg)

AIBW %
44.5 ± 15.8

31
*

48.5 ± 4.5
=

107.3 ± 17.1
above ideal body

68.4 ± 10.7

36.4 ± 11.2

Mean ± S.D. LBM

lean body mass. AIBW

weight. FM = fat mass. Patients ranged from 21 to 70% above ideal body weight.

weight9 (X% fat = 36.4 ± 11.2) (Table 1). Medical screening found them free of any physical, psychological, or metabolic impairment. These men had previously attempted to lose weight. Many had failed to lose significant amounts of weight, citing a discouraging inability to maintain the rate of weight loss demonstrated in the early phase of their weight loss regimen; others had been unable to maintain the weight loss they had achieved. To prevent any confounding of the measurement of RMR, patients were required to report to the pulmonary laboratory in the postabsorptive state (8-12 hours after the last meal). In addition, caffeine-containing beverages were prohibited during the premeasurement period, and subjects did not engage in any physical activity or smoke any cigarettes during that period. Patients rested for 30 to 45 minutes, reclined in a darkened, quiet, and comfortable room. Thereafter, while subjects rested supine in bed, one author (KP, with the help of an assistant, a trained, hospital-based pulmonary technician) measured resting metabolic rate (mRMR) every 30 seconds by indirect calorimetry, using the Beckman Horizon metabolic measurement cart (Beckman Instruments, Inc., Schiller Park, IL). The system measures oxygen consumption (V02 ml/min) and carbon dioxide production (CO2 ml/min). Resting metabolic rate was automatically calculated by the abbreviated Weir formula'0 and expressed in kcal/min and kcal/day by the equation: RMR in kcal/day = 3.94 X V02(L/min) + 1.1 X VCO2(L/min). Kcalories were converted to kj by multiplying them with the factor 4.18. To assure the validity of our RMR measurements, mean values achieved during the last 10 minutes of steady state (Fig. 1) were used in the calculations. Predicted resting metabolic rate (pRMR) was calculated from the Harris-Benedict Equation6 for males: RMR in kj/day = [5(H) + 13.7(W) + 66 - 6.8(A)] X 4.18, where H = height in cm, W = weight in kg (current and ideal), A = age in years. Comparisons between measured RMR (mRMR) and predicted RMR using current weight [pRMR (current)] or ideal weight [pRMR (ideal)] in the

HBE calculations were performed using a Student's two tailed t-test for paired data, with a level of significance set at alpha = 0.05. All analyses were done using the Statistical Analysis System (SAS, SAS Institute Inc., Cary, NC). Linear regression analysis was performed to assess the relationship between mRMR and pRMR, using both ideal weight and current weight in the HBE. Multiple regression analysis was used to describe the relationship between mRMR and the predictive variables height, age, weight, and per cent above ideal body weight (% AIBW) and to develop a clinically useful predictor equation for application in obese male populations.

Results Statistical analysis showed that the predicted values of RMR were indeed significantly different from the measured values in our obese, male population. Measured resting metabolic rate (mRMR = 8118 ± 1246 kj/day) was found to be significantly lower (p < 0.001) than predicted resting metabolic rate using current weight in HBE (pRMR (current) = 8811 ± 1129 kj/day). Measured RMR (mRMR) was significantly higher (p < 0.001) than pRMR (X = 6838 ± 556 kj/day) if ideal body weight was used in the calculation (Table 2). Measured RMR (mRMR) was 92 ± 10% of the pRMR (current weight) and 119 ± 12% of the pRMR (ideal) (Table 2). Individual variation of the mRMR ranged from 65 to 109% of the expected normal values, with only 64% of them having RMR within ± 10% of the expected (Fig. 2). When mRMR was expressed as per cent of expected, with ideal body weight in the HBE, only 26% of the paw

I-

0
4

_
E

6.0 '(calculating 5.8 5.6
5.4 5.2
1

Averoge value for mRMR

_

w

z CO

2

3

4

5

6

7

8

9

40

MINUTES
FIG. 1. Pattern of caloric needs

during steady state measurement.

138
Predicted (kj/day)

PAVLOU, HOE-ER, AND BLACKBURN
TABLE 2. Measured and Predicted Resting Metabolic Rate (RMR)*

Ann. Surg. * February 1986

RMR (Expressed as % Expected)

Measured

Current Weight

Ideal Weight 6838 ±556t (1636 ± 133 kcal)

(kj/day)

Ideal Weight 119 ± 12

Current Weight
92 ± 10

8811±1129t
(2108 ± 270 kcal)

8118±1246
(1942 ± 298 kcal)

Predicted = using Harris-Benedict equation. Measured = using Indirect Calorimetry. * = mean + S.D.; t = p < 0.001 vs. measured.

tients were found to be within ± 10% of the expected normal, with individual variation ranging from 76 to 150% of expected values (Fig. 3). Linear regression analysis showed a statistically significant (p < 0.001) correlation (r = +0.79) between mRMR and pRMR predicted by the HBE (Table 3). Multiple regression analysis with height, weight, age, and per cent of above ideal body weight as independent variables showed a statistically significant (p < 0.001) correlation (r = +0.81) between these indices and mRMR (Table 3). The regression equation resulting from our analysis: mRMR (kj/day) = [2089.7 - 8. 1(Ht) + 16.8 l(Wt) - 8.9(Age) - 1.03(% AIBW)] X 4.18 accounts for 66% of the variance in measured RMR.
Discussion The main reason for the observed reduction in the rate of weight loss among obese individuals with restricted ki40

lojoule intake has been attributed to the metabolic response to kilojoule restriction imposed. This restriction decreases resting metabolic rate (RMR), as reported in previous studies.' 2 The present investigation reports that even without kilojoule restriction, obese individuals are characterized by a suppressed RMR when compared to individuals of normal body weight and body composition. Our data are in general agreement with the findings of Feurer's recently published study8 reporting that obese individuals preparing to undergo gastric bypass surgery demonstrate a lower resting metabolic rate (mRMR) than is estimated by the Harris-Benedict formula (HBE). This should be of no surprise, since the HBE was derived from 136 male subjects with normal body weight and composition. No obese subjects were included in the population studied to develop the HBE.6 Although Feurer's study clearly demonstrates that "the resting energy expenditure of morbidly obese persons cannot be estimated accurately by the Harris-Benedict formula," it failed to derive a new equation that will more precisely estimate daily kilojoule needs. Feurer's correlation coefficients of +0.46 (r2 = 0.18) for the male population accounted for only a small amount of the variance

35-

30_
z 250.

Norma

*10
50

60

70.. 80

100 o MesrdRMR:as % of Epce (alon -CuretWeigt)
90

120
80
90

{00

41 0

120

t30 140

Mea

FIG. 2. When current body weight was used in the calculations, only 64% of the obese patients, as compared to 92% of Boothby's13 normal, healthy volunteers, had measured resting metabolic rates that were within + 10% of expected values.

d RM as % of Expced (Balon

FIG. 3. When ideal body weight was used in the calculations, only 26% of the patients had measured resting metabolic rates within ± 10% of the expected values.

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RESTING ENERGY EXPENDITURE IN MODERATE OBESITY TABLE 3. Regression Equation for Resting Metabolic Rate (RMR) in Men
r

139
r2 p <0.001 <0.001

RMR kj/day = [-169.1 + 1.02 pRMR (current)] X 4.18 RMR kj/day = [2089.7 - 8.17 H + 16.81 W - 8.9 A - 1.03 %AIBW] X 4.18
H = height (cm); W = weight (kg); A = age (years). pRMR = predicted

0.79
0.81

0.63
0.66

rent weight. %AIBW = per cent above ideal body weight.

resting metabolic rate with Harris-Benedict equation. WCW = with cur-

and thus are not of much clinical use. Their inability to develop a new equation may be attributed to the heterogeneity of the study population, which demonstrated a degree of obesity ranging from 57-226% above ideal body weight (% AIBW) and a mean (% AIBW) of 111 ± 35%. In comparison, we chose to study a more homogeneous group of obese male subjects, with a degree of obesity ranging from 21-70% AIBW (X = 44 ± 16% AIBW). The significant correlation coefficient of +0.81 (r2 = 0.66) found between mRMR and age, height, weight, and % AIBW indicates that these indices adequately predict the caloric needs of the metabolically active tissues in moderately obese male subjects (Table 3). The addition of the index of % AIBW as an independent variable in the multiple regression analysis increases the strength of

the relationship and indicates that the relative degree of obesity provides a significant factor in more precisely estimating RMR in moderately obese male subjects. The implications of this finding might be important, since, during the first 2 to 3 weeks on the dietary treatment, almost every patient demonstrates a psychologically gratifying rate of weight loss. As mentioned earlier, some of this weight loss is due to kilojoule deficit and some is due to protein and water losses.7 But a rather large number of patients drop out of treatment at 4 to 5 weeks, especially those patients on balanced deficit diets. Most often, these patients are generally classified as "noncompliant" despite the patients' insistence of the opposite. To demonstrate the extent of the possibility to miscalculate daily kilojoule needs in obesity when the HBE is

TABLE 4. Weight Loss in Two Patients

Patient A (Subject #6)
pRMR*
Weight (kg) Lean Body Mass (kg) Kcal/kg. LBM-' Height (cm) Age (yrs) Resting energy expenditure (kj/day) 20% added for daily activity (kj/day) Total kilojoule need (kj/day) Minus 10% metabolic suppression due to diet (kj/day) Actual kilojoule need (kj/day) Minus kilojoule intake (kj/day) Daily kilojoule deficit Kilojoule deficit in 7 weeks of
treatment

Patient B (Subject #30)
Measured
91.5 42.5 (46.5%) 27.8 pRMR
Measured

92.2 64.5 (70%) 28.7

180.0

183.0

59.0
7603

53.0
7511 (1797 kcal) 1651 7729

(1819 kcal)
1521 9125

4932 (1180 kcal) 986 5910

(1849 kcal)
1534 9263
928

9012
903

Weight loss (kg) (kj + 33,440) Comments:
* pRMR
=

911 594 8176 5325 4180 4180 -4034 -1145 -197,639 -56,121 (-47,282 kcal) (-13,426 kcal) 5.9 1.7 Dropped out during week 4 of the treatment without weight loss.

8109 8335 4180 4180 -3929 -3946 -192,531 -203,591 (-46,060 kcal) (-48,706 kcal) 5.7 6.1 Loss of 7.2 kg after 7 weeks of treatment.

using current weight in the HBE.

140

PAVLOU, HOEFER,

AND BLACKBURN

Ann. Surg. February 1986

used in the calculations, it is worth looking at two extreme cases from this study. Subjects #6 and #30 (Table 4) are characterized by similar age, weight, and height. If we utilize the Harris-Benedict Equation using current weight, we see that both patients are predicted to demonstrate similar daily kilojoule needs and would expect to demonstrate similar rates of weight loss. However, the RMR of Subject #6 was overestimated by 54%, or 2888 kj per day. Both subjects participated in a 7-week weight loss program with 4180 kj daily intake. Subject #6 dropped out of the study at week 4, unable to sustain a satisfactory rate of weight loss beyond the first 2 weeks of the study. As is illustrated in Figure 2, only 64% of the patients had metabolic rates within ± 10% of the expected values using current weight, whereas 92% of the normal body weight, healthy volunteers studied by Boothby13 had resting metabolic rates within ± 10% of the predicted. The mRMR of Patient B (Subject #30) of this study occurred at 101% of the expected. As is shown in Table 4, the weight loss predicted by using current weight in the HBE (5.7 kg) is similar in his case to predicted weight loss using mRMR in the calculations. In addition to the 4180 kj per day diet, the patient participated in a three-times-per-week exercise program and achieved 7.2 kg of weight loss. Like 36% of the subjects in this study, Patient A (Subject #6) demonstrated a metabolic rate of <90% (66%) of expected (Fig. 1); his mRMR was only 66% of expected. Patient A's metabolic rate was overestimated by 54% (4932 vs. 7603 kj/day). It should be clear from this discussion that for Patient A to register a similar rate of weight loss to Patient B, he should be placed on a very different weight loss regimen, such as a very-low-calorie-diet (2090 kj/day) requiring strict medical monitoring. It is of interest to note the similarities of the distribution between Feurer's data and ours when mRMR is expressed as per cent of expected, based either on current weight (Fig. 2) or ideal body weight (Fig. 3). When compared to normal weight and body composition population, the distribution clearly illustrates that RMR of obese individuals, as a group, is clearly suppressed (Fig. 2) but higher than if the individual's ideal body weight is used in the calculation (Fig. 3). Although our data show that moderately obese subjects demonstrate lower RMR than is estimated by the HBE, they are in general agreement with previous reports indicating that obese subjects have higher metabolic rates when compared to individuals with normal weight and body composition.'4"15 This increased metabolic rate is probably due to greater lean body mass (LBM) present in obese when compared to lean subjects,'6"'7 since LBM has been found to correlate highly with RMR.' "8"9 Resting metabolic rate expressed in kj per kg of body weight

(X = 76.5 ± 4.6) and kj per minute (X = 5.6 ± 0.8) was similar to values reported in other studies for obese individuals, and lower than those of normal weight and body composition.'5 However, when mRMR was expressed in kj per kg of LBM, obese individuals exhibit normal metabolic rate, as is demonstrated by this (X = 119.7 ± 64.8 kj X kg-' of LBM) and other studies'4"18 even in extreme cases, as is seen in Subjects A and B of this study (Table 4). The statistically significant differences between the mRMR and pRMR noticed in this study are due to changes in body composition resulting from the obese state, unaccounted for by the HBE. The increases in body weight in obesity are mainly due to increases in fat deposits and an accompanied moderate increase in LBM, which, although it creates a higher metabolic need, is not high enough to compensate for the parallel increase in body weight (fat). Thus, an explanation is provided for the lower metabolic needs noticed in this study. The HBE was developed to predict daily kilojoule requirements for normal weight and body composition individuals. The metabolically altered state of obesity requires a new equation that will more accurately account for these differences. The equation developed from this study accurately predicts daily energy expenditure for moderately obese male subjects with a degree of obesity ranging from 21-70% above ideal body weight, and its concluding possible applications and ways to test their usefulness should be considered. Acknowledgments
The authors wish to thank the subjects who volunteered for the study and the pulmonary technician, Patricia Carroll, for her assistance in indirect calorimetry.

*

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IN MODERATE OBESITY