Clinical Controversies
Adjusted Body Weight, Con: Why Adjust Body Weight in
Energy-Expenditure Calculations?
Carol Ireton-Jones, PhD, RD, LD, CNSD, FACN
ABSTRACT: Evaluation of energy requirements of nor-
mal individuals and hospitalized patients is most often
accomplished using an energy equation. Energy equations
attempt to measure resting metabolic rate (RMR), the
largest factor in total daily energy expenditure. Compo-
nents of most energy equations include height, weight,
age, and gender. These factors are related to energy
expenditure; however, each factor has individual charac-
teristics that affect energy expenditure. Body weight is a
major factor in RMR and total daily energy expenditure.
For obese individuals, estimation of energy expenditure
may be a challenge due to the increased body weight.
Therefore, some equations attempt to minimize the effect
of body weight on energy expenditure assessment by
adjusting the obese individuals body weight. Data do not
support adjustment of body weight in normal individuals.
In hospitalized patients, there are several equations that
are used to estimate energy expenditure of obese patients,
which include adjusting the body weight and modifying
the overall energy requirements. Measurement of RMR
can obviate the need for estimating energy expenditure. It
is important to evaluate any energy-expenditure equation
that is used to estimate energy needs in normal people
and hospitalized patients before applying it to patient
care.
Because evaluation of energy needs is one of the
first steps in nutrition assessment of patients, an
energy-expenditure equation is most often used to
make this calculation. There are more than 200
equations published for energy expenditure using
many variations of factors to attempt to predict
resting metabolic rate (RMR) or total energy expen-
diture (TEE). Body weight is used in most equations.
Obesity confounds the application of the body weight
Correspondence: Carol Ireton-Jones, PhD, RD, LD, CNSD,
FACN, Nutrition Therapy Specialist, 1730 Countryside Drive,
Carrollton, TX 75007. Electronic mail may be sent to dr.
cijrd@verizon.net.
0884-5336/05/2004-0474$03.00/0
Nutrition in Clinical Practice 20:474479, August 2005
Copyright 2005 American Society for Parenteral and Enteral Nutrition
474
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factor, and therefore, body weight may be adjusted
by some practitioners for use in an energy expendi-
ture equation. Before investigating the practice of
adjusting body weight in energy-expenditure equa-
tions, it is important to review the framework for
developing an evidence-based approach to nutrition
intervention such as adjusting body weight in an
energy equation. Perhaps application of an evi-
dence-based approach to nutrition interventions has
not been considered in the adjusted body weight
calculation. Various levels of evidence are used to
set up an evidence base, including systematic review
and meta-analysis, which is the strongest type of
evidence.1 A review of the levels of evidence, with
level I being the highest and most significant and
level VI being the lowest, is found in Table 1. These
levels can be used to grade the evidence of an
intervention, whether medical or nutritional. There-
fore, with a review of the components of energy
expenditure and the data supporting the equation
used, the evidence related to adjusted body weight
for energy equations can be analyzed or graded
using this system.
Elements contributing to daily energy expendi-
ture are height and weight, age, gender, race, and
physical activity.2 RMR, which can be measured
with acceptable accuracy, includes the contribution
of height, weight, age, race, and gender but does not
Table 1
Levels of evidence for clinical effectiveness (Cochrane Library
Training Guide)
I. Strong evidence from at least 1 systematic review of
well-designed, randomized clinical trial (RCT).
II. Strong evidence from at least 1 properly designed RCT
of appropriate size.
III. Evidence from well-designed trials without
randomization: single-group, pre-post; matched case
controlled.
IV. Evidence from well-designed, nonexperimental studies
from more than 1 center or research group.
V. Opinions from respected authorities, based on clinical
evidence, descriptive studies or reports of expert
committees.
VI. Someone once told me.
Reprinted with permission from Stratton RJ, Green CJ, Elia M.
Disease-Related Malnutrition: An Evidence-Based Approach to
Treatment. Cambridge, MA: CABI Publishing; 2003:159.
August 2005 ADJUSTED BODY WEIGHT IN ENERGY-EXPENDITURE CALCULATIONS
include the thermic effect of food or effect of physical
activity on metabolic rate.3 Because height, weight,
and age are static measured numbers and gender
and race are predetermined, only physical activity
leaves room for variation in calculated equations.
However, many clinicians also modify body weight
in equations for hospitalized patients when they are
overweight or obese.4 Therefore, why is body weight
adjusted?
Factors Related to Energy Expenditure
Age is a determinant of energy expenditure as it
relates to children. Children have higher metabolic
rates per kg than do adults. Keys et al5 evaluated
the effect of age on metabolic rate and found that
aging has only a small effect on metabolic rate per
decade. Luhrman and Neuhaeuser6 evaluated vari-
ous predictive equations by comparing calculated
RMR with measured RMR (using indirect calorime-
try) in a large group of elderly subjects (mean age of
both men and women was 67 years). In both men
and women, RMR was on average underestimated
by up to 7.5% with an equation based on body
weight, by up to 4.5% with an equation based on
both weight and height; and up to 4.6% on an
equation based on weight, height, and gender.
Although this could be considered a small variation,
estimation errors for each individual may be high,
suggesting that RMR should be measured instead of
estimated in the elderly. A similar smaller study
was done on a population of very old individuals
(mean age, 86 years). When predicted RMRs were
grouped, there was little difference between pre-
dicted and measured RMR.7 However, there were
large differences between predicted and measured
RMR when patients were stratified by activity sta-
tus (awake and minimally active vs bedridden), with
those who were bedridden having very low mea-
sured RMRs consistently. Gender is also a factor in
energy equations, with men requiring more kcal
than women in equations that include gender as a
factor to account for a higher lean body mass. Height
is used in most energy-expenditure equations, espe-
cially those used to determine energy needs accord-
ing to ideal or desirable body weight. For example,
the Hamwi8 formula uses height and weight to
determine ideal body weight (IBW), and body mass
index (BMI) is calculated using height and weight
ratios.9 The BMI was developed to relate body
weight and height ratios to body weight and there-
fore risk of certain diseases. This risk ratio applies
for high and low BMIs. Age, height, and gender are
factors often used in equations to estimate energy
expenditure, and each of these factors is a variable
in predicting energy expenditure.
Body Weight
Body weight is a component of equations to pre-
dict energy expenditure in normal individuals and
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475
Table 2
MifflinSt. Jeor and Owen equations
MifflinSt. Jeor equations
Males: EE 10(W) 6.25(H) 5(A) 5
Females: EE 10(W) 6.25(H) 5(A) 161
(EE kcal/day, W weight in kg, H height in cm, A
age in years)
Owen equations
Males: EE 879 10.2(W)
Females: EE 795 7.2(W)
(EE kcal/day, W weight in kg)
Harris-Benedict equations
Males: EE 66 13.8(W) 5(H) 6.8(A)
Females: EE 655 9.6(W) 1.8(H) 4.7(A)
(EE kcal/day, W weight in kg, H height in cm, A
age in years)
hospitalized patients. Fat mass (FM) and fat-free
mass (FFM) are components of body weight that are
related to energy expenditure.10 In women, meta-
bolic rate is lower than men due to a greater amount
of adipose tissue. Studies have shown that differ-
ences in metabolic rate/kg FFM are less apparent
between men and women.10,11 Aging and gender
differences influence RMR through the variation in
FM and FFM. In studies analyzing the effect of body
composition on RMR, individuals who had the same
FFM demonstrated RMRs that varied 25%50% due
to the contribution of energy expenditure from
FM.11 Body composition was analyzed using skin-
folds, densitometry, total body potassium, and water
dilution. Although these methods are well accepted,
there are academic difficulties in using these meth-
ods due to hydration status (related to total-body-
water analysis), osteoporosis, race, and technique in
normal subjects. These would be further com-
pounded in hospitalized patients. Given the vari-
ability of body composition measurements, the only
way to reduce the error rate is to use several
methods to assess body composition in the same
individual. Therefore, measurements of FM and
FFM are not applicable in the hospitalized patient.
This demonstrates that there is not a fixed number
to estimate the percent of FM that is metabolically
active and contributes a specific amount of kcal to
overall energy expenditure. This will vary by indi-
vidual and even among equations used to estimate
FM and FFM in one individual.11
Extremely overweight and underweight individu-
als pose a challenge in estimating energy expendi-
ture because their body weight is outside that rec-
ognized as ideal or desirable. Body weight is
included in the many equations, including those
developed by Harris and Benedict,12 Mifflin et al,13
and Owen et al14,15 (Table 2). Because both FFM and
FM contribute to RMR, when energy expenditure is
predicted using actual body weight in obese individ-
uals, it will be higher than when using an ideal or
adjusted weight. Das and colleagues16 found that
extremely obese normal women (BMI 37.577) have
476
high measured RMRs and TEE, with both RMR and
TEE increasing as BMI increases. In this study of 30
obese women, the Harris-Benedict equation was
accurate in estimating the RMRs when actual body
weight was used. It is interesting to note that the
authors of this study further found maintenance of
the excess body weight is due to high energy intakes.
Das et al17 also studied RMR after significant weight
loss through gastric bypass and found that RMR
decreased due to decreases not only in FM but FFM
as well.
The goal of a nutrition support regimen for an
obese person would be to provide adequate calories
to support the FFM and only a portion to support
FM. Therefore, an energy-expenditure equation that
was able to predict this energy expenditure would be
very useful. The problem continues that FM does
contribute to energy expenditure and that both FFM
and FM are difficult to measure in clinical settings.
The term that appears in the literature related to
the portion of FM to be supported is metabolically
active tissue. The question then becomes, how much
of the excess body weight is metabolically active
tissue, and second (or perhaps first), how does one
determine what is excess body weight and what is
normal or ideal/desirable body weight? The BMI
does not provide relative amounts of FM or an IBW
number but is an assessment tool for determining
the presence of obesity. A BMI of 30 kg/m2 or more is
often used as an indicator of obesity and is a consid-
eration in developing a nutrition-support regimen
for critically ill or injured patients. The Hamwi8
formula is a simple method for predicting IBW and
uses an individuals height and gender for estima-
tion. To calculate the IBW for men, use 106 pounds
for the first 5 feet of height and add 6 pounds per
inch above 5 feet. A man who is 67 inches tall would
have an IBW of 148 pounds. For women, use 100
pounds for the first 5 feet of height and add 5 pounds
per inch above 5 feet. A 67-inch tall woman would
have an IBW of 135 pounds. The Metropolitan Life
Insurance tables have been used to determine IBW
in relation to height, gender, and age.18 Because the
Metropolitan tables are based on weights of people
who are able to obtain insurance, the IBW has
continued to increase over the years as body weights
have increased. At least 1 study recommends using
the 1959 Metropolitan Life insurance tables to iden-
tify obesity in hospitalized patients.19
One area that seems to have a firm foundation in
adjusting body weight is in drug dosing specifically
related to aminoglycosides.20 In an obese patient
(obese being defined as 130% of IBW), it is recom-
mended to add a factor of 40% of the excess body
weight to the IBW to account for metabolically
active tissue (adjusted body weight IBW
{[actual body weight IBW] 0.40}).21 This
adjusted body weight is used in aminoglycoside
dosing. Cocoran and Salazar22 studied the effect of
obesity on the nephrotoxic potential of gentamicin
and found that when total body weight was used to
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IRETON-JONES Vol. 20, No. 4
calculate gentamicin dosage in rats, nephrotoxicity
was significantly increased. Even using a factor of
40% for metabolically active tissue, there was neph-
rotoxicity seen in the obese rats. Monitoring the
patients for efficacy of the drug therapy is always
recommended. The use of this factor has been stud-
ied and derived from strong evidence from at least 1
properly designed randomized controlled trial of
appropriate size, making it level-II-grade evidence.
This adjustment factor for obese patients can be
found on several websites on drug dosing; however,
the original reference for the factor is not given.
Interestingly, on another website with information
on drug dosing for obese patients, it was suggested
that the body-weight adjustment factor was 30%,
and referred to a drug-dosing website as their source
for the adjustment factor, quoting the website incor-
rectly. This presents an argument for finding the
source for any factor to be used in clinical patient
management. Given that this factor is used in drug
dosing and has clinical data behind it, what factors
are used in the nutrition community for estimating
the metabolically active component of excess body
weight in obese patients to use in energy expendi-
ture equations?
The most common factor for adjusting the body
weight of obese people used by clinicians in predic-
tive energy equations is a factor of 25%.4 The for-
mula implies that only 25% of the excess body
weight in an obese person (obese being 130% of IBW)
is metabolically active.23 Finding the original refer-
ence for the factor is difficult because it was pub-
lished in the Renal Dietitians Newsletter, a publica-
tion of the American Dietetic Association, in 1984.
This author has not seen the actual publication;
however, it is supposed that the equation so often
used is listed as adjusted body weight IBW
{(actual body weight IBW) 0.25}, where IBW is
determined by the Hamwi8 formula. Because there
appears to be no original research on this equation,
this would receive a level VI rating as someone once
told me. This adjusted body weight factor is used in
conjunction with the Harris-Benedict equation and
has been widely distributed and widely accepted
among dietetics practitioners. Additionally, it has
been passed on to nursing and other practitioners
for use with obese people and obese ill and critically
ill patients.4,24
Frankenfield and colleagues25 evaluated the use
of several equations for estimating RMR and com-
pared results with those from measured RMR using
indirect calorimetry in obese and nonobese normal
subjects. Additionally, the study evaluated the accu-
racy of the adjusted body weight factor of 25% for
obese people (BMI 30 kg/m2) in the Harris-Bene-
dict equations compared with the measured RMR.
Results demonstrated that use of adjusted body
weight was associated with a significant underesti-
mation of RMR compared with the use of actual body
weight. This discrepancy was heightened when the
BMI was 40. For all equations studied, the errors
August 2005 ADJUSTED BODY WEIGHT IN ENERGY-EXPENDITURE CALCULATIONS
were more likely to be overestimations when using
actual body weight in the equations. The authors
conclude that the use of adjusted body weight
caused underestimation of RMR and is not helpful in
clinical application for obese individuals. It should
also be mentioned that the Harris-Benedict equa-
tions are often inaccurate for normal-weight individ-
uals. In the study by Frankenfield et al,25 the
Harris-Benedict equation was inaccurate in predict-
ing RMR 33% of the time, with the errors tending to
be overestimations using actual body weight. The
data presented in this article by Frankenfield et al25
represent level IV evidence. Therefore, using an
evidence-based-medicine approach, adjusted body
weight should not be used in estimating the energy
expenditures of obese normal individuals.
Barak et al26 evaluated an adjusted body weight
factor of 50% to estimate the energy expenditure in
the obese patient (adjusted BW IBW [actual BW
IBW 0.50]); IBW determined by the Hamwi8
formula). This body weight was used in conjunction
with the Harris-Benedict equation and a stress
factor of 1.25. This was a large, retrospective study
of 567 patients with a mean age of 54 years. The
data indicated that energy expenditures can be
predicted in obese patients using the Harris-Bene-
dict equation incorporating the 50% adjusted-body-
weight calculation and multiplied by a factor of 1.25.
Other variations in body weight and stress factors
have been proposed for use with obese patients.2729
Energy expenditure prediction using standard
equations can vary in accuracy, whether calculated
using body surface area or using height, weight, age,
and gender. This variability is inherent for normal
weight and obese individuals. Frankenfield and col-
leagues25 reviewed 3 standard equations, as found
in Table 2, for predicting RMR of normal subjects
and compared these to measured RMR to provide
insight to the practitioner as to the applicability of
the equations in both obese and normal weight
individuals. Actual body weight was used in the
equations. For normal weight individuals, the
MifflinSt. Jeor equation was more accurate more
often than the Harris-Benedict or Owen equations,
and it is recommended for normal weight individu-
als. The MifflinSt. Jeor equations were published
in 1990 and included 251 men and 247 women, of
which 47% had a BMI between 30 and 42 kg/m2.13
Even in obese individuals, the MifflinSt Jeor equa-
tion is more accurate more often than the Harris-
Benedict or Owen equations and is recommended for
obese individuals, as well. The MifflinSt. Jeor
equation has been evaluated recently using data
from more than 1400 subjects who had RMR mea-
sured and predicted and again found to have a high
correlation with RMR over other equations (Sachiko
St. Jeor, personal oral communication, January,
2005).
If one does not use adjusted body weight for obese
patients and uses actual body weight, predicted
energy expenditure will reflect the increased propor-
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477
tion of body mass. There are equations that use
actual body weight. The Ireton-Jones equations,
developed from measurements of RMR of hospital-
ized patients for use with the same population, use
actual body weight for all patients. The presence of
obesity is accounted for by the varying factors in the
ventilator-dependent and spontaneously breathing
equations.19,30 In a study of critically ill, mechani-
cally ventilated patients, the Ireton-Jones equations
and 3 versions of a multivariate equation were used
to predict RMR and to compare with measured RMR
using indirect calorimetry.31 Although a larger per-
centage of the patients RMR was accurately pre-
dicted by the Penn State equations vs the Ireton-
Jones equations, this was not statistically
significant; however, the incidence of errors 15%
was significantly lower with the Penn State equa-
tions. The Penn State equation incorporates the
Harris-Benedict equation calculation (using actual
body weight for obese and nonobese subjects) multi-
plied by 0.85 with mathematical calculations added
for minute ventilation and maximum body temper-
ature. Some of the improvement in predictability of
RMR by the new equation is because their study
population included an increased number of obese
and elderly patients, as seen more recently in the
ICU setting.
McCowen et al32 studied energy requirements of
obese and nonobese hospitalized patients. A stan-
dard 25 kcal/kg regimen was compared with a
hypocaloric feeding regimen in obese and nonobese
ICU patients who were fed parenterally. Average
blood glucose levels, frequency of hyperglycemia,
and infection rates were similar for both groups.
Therefore 25 kcal/kg actual body weight may be
useful predicting the energy requirements of both
obese and nonobese ICU patients. Continued moni-
toring of response to nutrition therapy of all patients
remains essential.
Measurement of RMR
Measurement of RMR by indirect calorimetry
includes the contributions of height, weight, age,
and gender to energy expenditure but does not
include the thermic effect of food or physical activity
on metabolic rate. When measured in ill or injured
patients, the effect of the illness or injury on RMR is
also measured. In the previous literature reviewed,
all studies using adjusted body weight to predict
energy expenditure and all predictive equations
were compared with measurement of RMR by indi-
rect calorimetry. All the predictive equations
attempted to modify weight, stress factors, or other
factors to allow prediction of measured RMR. Deter-
mination of energy expenditure in critically injured
patients is difficult with standard or even modified
equations, and none have 100% agreement to indi-
rect calorimetry. Therefore, measurement of energy
expenditure in critically ill patients, especially the
very thin and those who are obese, seems to be most
478 IRETON-JONES
clinically applicable. Indirect calorimetric measure-
ments should be made under standard conditions
and completed by a skilled technician or clinician.33
Studies in critically ill patients have shown that
measurement of energy expenditure until a steady
state is obtained will produce an accurate RMR.34,35
Energy expenditure should be measured using indi-
rect calorimetry for critically and acutely ill patients
with confounding factors such as obesity.33,36,37
Summary
It is always important to review the original
research related to any energy expenditure equation
and determine the appropriateness to the popula-
tion to which it will be applied.38,39 The Harris-
Benedict equations published in 1919 are not easy to
obtain in their original reference. Because of this,
the Harris-Benedict equations have been written
incorrectly in articles and even textbooks.40 There-
fore, before adjusting individual components of any
energy equation, it is important to review the orig-
inal research related to the equation and determine
its applicability.
In applying all of this information to practice,
especially in the critically ill patient, it seems rea-
sonable to use an equation that incorporates actual
body weight. A simple equation for this would be
25 kcal/kg. A more concise equation would be the
Ireton-Jones or Penn State equations. Use of the
MifflinSt. Jeor equation for normal obese individ-
uals may also be applicable for hospitalized obese
patients and has been suggested by other
authors.31,41 Measurement of RMR obviates the use
of any energy expenditure equation and should be
considered an important component of nutrition
assessment in the hospitalized patient.39,42
Determining the energy expenditure of an obese
person or an extremely underweight person is diffi-
cult. In the normal individual, under- or overfeeding
can be recognized and treated over time, such as
with weight-gain or weight-loss nutrition regimens.
However, with an ill, injured, or critical patient in
the ICU, the margin for error is less when an
inappropriate feeding regimen is used. There is no
substitute for clinical judgment in the evaluation of
patient progress, patient clinical status, and appli-
cation of an equation for estimating energy needs.
Clinical judgment comes from practice, but it also
comes from critical review of literature. If clinicians
are confident in using adjusted body weight, they
should be sure that the use is based on data and not
someone once told me. The tenet we all abide by in
medical practice may be modified for nutrition sup-
port practice: feed the patient, but do no harm.
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