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Meta-Analysis
. 2025 Aug 1;83(8):1425-1437.
doi: 10.1093/nutrit/nuaf042.

Association Between Energy Delivery and Outcomes in Adult Critically Ill Patients Diagnosed With or At Risk of Malnutrition: A Systematic Review and Meta-analysis With Trial Sequential Analysis

Shu Han Chong  1 , Yingxiao Huang  2 , Mei Shan Heng  3 , Elizabeth Sin Tzun Chong  4 , Cassandra D Q Lim  5 , Kok Wah Wong  6 , Hiu Nam Chan  7 , Daren K Heyland  8 , Christian Stoppe  9   10 , Charlene Compher  11 , Zheng-Yii Lee  9   10   12 , Alvin Wong  2 , Charles Chin Han Lew  1   13
Affiliations
Meta-Analysis

Association Between Energy Delivery and Outcomes in Adult Critically Ill Patients Diagnosed With or At Risk of Malnutrition: A Systematic Review and Meta-analysis With Trial Sequential Analysis

Shu Han Chong et al. Nutr Rev. .

Abstract

Context: There is a common belief that adult critically ill patients diagnosed with or at risk of malnutrition would benefit from higher energy delivery.

Objective: This systematic review and meta-analysis aimed to evaluate the association between energy delivery and mortality in adult critically ill patients diagnosed with or at risk of malnutrition.

Data sources: Databases including Medline, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central, and Google Scholar were searched from inception to November 20, 2023.

Data extraction: Randomized controlled trials (RCTs) and observational studies that (1) included critically ill patients (aged ≥18 years) diagnosed with or at risk of malnutrition using validated tools following intensive care unit (ICU) admission, (2) had at least 20% energy difference between intervention and comparison groups, and (3) reported mortality outcomes were included. The random-effects model was used to pool the data.

Data analysis: Two RCTs (4681 at-risk patients) and 5 observational studies (1587 at-risk patients [including 389 high-risk patients]) were included. The pooled mean energy delivered during the first 7-14 days of ICU admission in higher vs lower energy groups was 25.6 ± 5.9 vs 9.7 ± 5.6 kcal/kg per day (P = .004) in RCTs and 21.0 ± 5.2 vs 13.3 ± 5.3 kcal/kg per day (P < .001) in observational studies. No mortality difference was found between higher vs lower energy groups in at-risk patients (risk ratio: 0.99; 95% CI: 0.85, 1.17; P = .94) in RCTs and high-risk patients (adjusted odds ratio: 1.37; 95% CI: 0.43, 4.32; P = .59) in observational studies. Trial sequential analysis was performed and 31 232 patients were required to show a potential treatment effect.

Conclusion: These data do not support the prevailing belief that higher energy delivery improves survival in adult critically ill patients diagnosed with or at risk of malnutrition.

Systematic review registration: PROSPERO registration no. CRD42021274378.

Keywords: caloric intake; critical care; energy intake; malnutrition; nutritional assessment; nutritional screening.

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