My Kingdom for (Cessation of) a Calorie Count

Today a patient on my floor with underlying dementia and recent refusal of meals was ordered a calorie count by the attending doctor. Most dietitians likely have seen calorie counts before but they are what they sound like. A nurse or tech documents the amount of foods that a patient eats. The dietitian then takes that documentation, calculates the kcals and protein, and then determines if the person is meeting their calorie and protein needs.

Why Are They Ordered?

Calorie counts are great tools when you need documentation to back up a

recommendation. For example, a dietitian can use the results of a calorie count to recommend discontinuing nutrition support if a patient is eating adequately. Or, recommend initiating nutrition support for a person who is not maintaining adequate intake.

In short, a calorie count is a tool. Like every other tool we use, it has a specific purpose and appropriate usage. However, it’s often used when clinicians are at a loss of what to do with a patient. Ordering a calorie count is active and seems like it’s beneficial. When used appropriately, it can be a powerful tool.

Why should you not order a calorie count though? Although I’ve not seen a decision tree or other general guidelines for calorie counts, I would propose these general questions to consider before ordering or recommending one in the inpatient setting.

1. Will The Results Change My Recommendation?

If you order a calorie count on an elderly person with dementia, you’ll probably find that this person is not meeting his or her kcal needs. But what will you do about that? In a relatively young person, an acute illness, or a motivated patient, you’ll find the calorie count can provide evidence for or against nutrition support. However, that elderly person with dementia will suffer greater harm from long-term nutrition support. Feeding a person may seem necessary even at an older age, but we should not routinely recommend a course of action that could cause increased mortality.

2. Are We Using Resources Responsibly?

A calorie count takes time to document and calculate. The nurse or tech has to monitor a person’s intake closely and the dietitian has to calculate a person’s intake. While a three-day count may only take a few hours of time overall, time in an inpatient setting is valuable. Before you add to the workload of the nursing staff as well as your own patient load, consider whether you actually need to use those resources. In most cases, a general percentage of intake is documented and, if not, speaking to a nurse about improving that documentation may be the best option.

3. Does It Mask the Actual Problem?

In my current patient, her intake is only one of the many problems. Overall, it appears as though she is declining. Her poor appetite certainly isn’t helping but good nutrition does not cure dementia. Of course encouraging intake may help with her symptoms and possibly even quality of life, but are we forgetting her medical problems in pursuit of poor nutrition? Are we forgetting to see her as a person before her medical or nutrition-related problems? I don’t know what this woman or her family wants, but we need to have that conversation before making any major decisions regarding her care.

Final Thoughts

Calorie counts aren’t a great evil. They’re not invasive and, while annoying, they can be a useful tool. However, when used inappropriately, calorie counts increase the workload for nursing, CNAs, and dietitians without providing information that will improve patient care or outcomes. Ideally, we should develop specific guidelines for responsible ordering of calorie counts. At my facility, we haven’t developed those, but they would be remarkably helpful for all of our staff.

That’s my opinion and I’m sticking with it.