OBJECTIVES

Energy Metabolism and

Normal Nutritional
R
Requirements
i
t

To review normal protein,

carbohydrate and lipid metabolism
To understand the mechanisms that
regulate substrate utilization and
energy production
To demonstrate methods for
calculating nutritional requirements

FERNANDO L. LOPEZ, MD, FPCS

Professor of Surgery
UST Department of Surgery

Glucose Metabolism

NUTRIENTS

Protein
Carbohydrates
enteral
parenteral
Lipids
Water
Vitamins

4 kcal / g

Glucose

4 kcal / g
3.4 kcal / g
9 kcal / g

Cori
Cycle

MITOCHONDRIA

Pyruvate

Krebs
Cycle

Pyruvate

ATP

AcetylCoA

Water soluble
Fat soluble

CYTOPLASM
Glucose

Lactate
Lactate

Minerals
Electrolytes
Trace elements and ultra trace minerals

Lieberman MA, Vester JW. Carbohydrates. In: Nutrition and Metabolism in the Surgical Patient.
Boston, MA: Little, Brown and Company;1996:203-236.

Fatty Acid Metabolism

Amino Acids
ESSENTIAL

CAPILLARY

Triglycerides

CYTOPLASM
Fatty Acids
Carnitine

MITOCHONDRIA

Fatty Acids
Fatty Acids
+
Glycerol

ATP
Oxidation

Triglycerides

Fischer JE, ed. Nutrition and metabolism in the surgical patient. Boston, MA: Little, Brown and
Company; 1996.

Leucine
Lysine
Valine
Threonine
Isoleucine
Phenylalanine
Methionine
Histidine
Tryptophan

CONDITIONALLY ESSENTIAL

Glutamine
Arginine

NON-ESSENTIAL

Alanine
Tyrosine
Aspartic Acid
Glutamic Acid
Cysteine
Glycine
Serine
Proline

Fischer JE, ed. In: Nutrition and Metabolism in the Surgical Patient. 1st ed. Lippincott Williams and
Wilkins Publishers; 1996.

Nitrogen Balance

Chemical Structure of an Amino Acid

COOH

NB = IN (UN + RNL)

NB:
IN:
UN:
RNL:

NH3

Nitrogen Balance
Ingested Nitrogen
24-Hour Urine Nitrogen
Remaining Nitrogen Loss (3.1 g/d)

Fischer JE, ed. In: Nutrition and Metabolism in the Surgical Patient. 1st ed. Lippincott Williams
and Wilkins Publishers; 1996.

Respiratory Quotient (RQ)

RQ

VCO2
VO 2

Glucose oxidation
1 glucose + 6 O2 = 6 CO2 + 6 H20

Respiratory Quotient
CO2 Produced
Oxygen Consumed

Fat oxidation
1 palmitate + 23 O2 = 16 CO2 + 16 H2O

Protein oxidation
4.1/5.1 = 0.8
1 amino acid + 5.1 O2 = 4.1 O2 + 2.8 H2O

Lipogenesis

RQ =
RQ:
VCO2:
VO2:

Respiratory Quotient (RQ)

Regulation
Nutrient availability
Hormonal environment
Inflammatory state

16/23 = 0.7

> 1.0 8.0

Excess Glucose Supply

Nutrient Utilization

6/6 = 1.0

Glucose
Glucose

CO2
CYTOPLASM
Lipogenesis
Triglycerides
Acetyl CoA
MITOCHONDRIA

Pyruvate

Pyruvate

Krebs
Cycle

ATP

Acetyl CoA

Inflammatory Response

Excess Fatty Acid Supply

Free Fatty Acids

CYTOPLASM

Glucose

CYTOPLASM

Glucose
F tt Acids
Fatty
A id
MITOCHONDRIA

Carnitine

Fatty Acids

Ketones

Cori
Cycle

MITOCHONDRIA

Pyruvate

Oxidation

low insulin

CYTOPLASM

Fatty Acids
+
Glycerol

Fasting state:
Depends
p
on nutrient availabilityy

In stress:
Depends on hormonal environment and
inflammatory response

TNF, IL-1

Carnitine

TNF

MITOCHONDRIA

Fatty Acids

ATP

Oxidation

ATP

Energy Substrate Utilization

Inflammatory Response

Fatty Acids

Krebs
Cycle

BLOCKAGE

Triglycerides

Triglycerides

Lactate
Lactate

CAPILLARY

TNF
IL1
IL6

Acetyl CoA

Acetyl CoA

high insulin

Pyruvate

Triglycerides

Body Composition

Malnutrition

Weight (kg)

70

60

Total Water (L)

42

31

Intracellular

28

19

Extracellular

14

12

28

28.8

Fat (kg)

12.5

17

BCM
Protein (kg)

12.5

Total Solids (kg)

Minerals (kg)

BCM = Body Cell Mass

Ideal Weight
Actual Weight
g

In malnutrition, energy expenditure must be calculated

based on actual body weight.

Obesity

Calculating Basal Energy Expenditure

Ideal Weight

Harris-Benedict Equation
Variables
gender, weight (kg), height (cm), age (years)
Men:

Actual Weight
g

66.47 + (13.75 x weight) + (5 x height) (6.76 x age)

Women:

655.1 + (9.56 x weight) + (1.85 x height) (4.67 x age)

Calorie requirement = BEE x activity factor x stress factor

In obesity, energy expenditure must be calculated on ideal weight.

Calorie Calculation

Rule of Thumb
Calorie requirement = 25 to 30 kcal/kg/day

Metabolic Response to
Starvation and Trauma:
Nutritional Requirements

Fasting Early Stage

Objectives
Muscle

Alanine / Pyruvate

Explain the differences between metabolic

responses to starvation and trauma
Explain the effect of trauma on metabolic rate and
substrate utilization
Determine calorie and protein requirements during
metabolic stress

Brain

Glucose

Glutamine
Glycerol

Gluconeogenesis
Ketogenesis

Fat

AGL

Ketones
Liver

Ureagenesis
Ketones

Urea
NH3

Intestine

Kidney

Fasting Late Stage

Metabolic Reaction to Starvation

Muscle

Alanine / Pyruvate

Brain

Glucose

Glutamine
Glycerol

Gluconeogenesis
K
Ketogenesis
i

Fat

Ketones

AGL

Liver

Ureagenesis
Ketones

Source

Norepinephrine
o ep ep
e
Norepinephrine
Epinephrine
Thyroid Hormone T4

Sympathetic Nervous
System
Adrenal Gland
Adrenal Gland
Thyroid Gland (changes to
T3 peripherally)

Urea
NH3

Change in Secretion

Hormone

Kidney

Intestine

Landberg L, et al. N Engl J Med 1978;298:1295.

Metabolic Response to Trauma

Energy Expenditure in Starvation

Ebb Phase
Normal Range

Partial Starvation

Flow Phase

Energy Expen
nditure

Nitrogen Excrettion (g/day)

12

Total Starvation
0

10

20

30

Time

40

Days

Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55

Long CL et al. JPEN 1979;3:452-456

Metabolic Response to Trauma: Ebb Phase

Metabolic Response to Trauma: Flow Phase

Characterized by hypovolemic shock

Priority is to maintain life/homeostasis
Cardiac output
Oxygen
O
consumption
ti
Blood pressure
Tissue perfusion
Body temperature
Metabolic rate

Cuthbertson DP, et al. Adv Clin Chem 1969;12:1-55

Welborn MB. In: Rombeau JL, Rolandelli RH, eds. Enteral and Tube Feeding. 3rd ed. 1997

Catecholamines
Glucocorticoids
Glucagon
g
Release of cytokines, lipid mediators
Acute phase protein production

Cuthbertson DP, et al. Adv Clin Chem 1969;12:1-55

Welborn MB. In: Rombeau JL, Rolandelli RH, eds. Enteral and Tube Feeding. 3rd ed. 1997

Metabolic Response to Trauma

Metabolic Response to Trauma

Liver & Muscle

(glycogen)

Endocrine
Response

Glucose

Muscle
(amino acids)

Amino Acids

Nitrogen Excretion (g/day)

28

Fatty Acids

Fatty Deposits

24
20
16
12
8
4
0
10

20

Days

30

40

Long CL, et al. JPEN 1979;3:452-456

Metabolic Response
to Starvation and Trauma

Severity of Trauma: Effects on Nitrogen

Losses and Metabolic Rate

Nitrogen Loss in Urine

Major
Surgery

Metabolic rate
Bodyy fuels
Body protein
Urinary nitrogen
Weight loss

Moderate to Severe
Burn

Severe
Infection Sepsis
Elective
Surgery

Calorie Distribution Shift in Catabolism

NORMAL

25%

30%

Fat

CHO
60%

wasted
wasted

slow

rapid

Determining Calorie Requirements

CATABOLIC
15%

Protein

conserved
conserved

Popp MB, et al. In: Fischer JF, ed. Surgical Nutrition. 1983.

Adapted from Long CL, et al. JPEN 1979;3:452-456

Fat

Trauma or Disease

The body adapts to starvation, but not in the

presence of critical injury or disease.

Basal Metabolic Rate

25%

Starvation

Protein

Indirect calorimetry
Harris-Benedict x stress factor x activity factor
25-30 kcal/kg body weight/day

CHO
45%

Metabolic Response to Starvation and

Trauma: Nutritional Requirements
Injury
Minor surgery
Long bone fracture
Cancer
Peritonitis/sepsis
Severe infection/multiple trauma
Multi-organ failure syndrome
Burns
Activity
Confined to bed
Out of bed

Stress Factor
1.00 1.10
1.15 1.30
1.10 1.30
1 10 1.30
1.10
1 30
1.20 1.40
1.20 1.40
1.20 2.00

Metabolic Response to Overfeeding

Example:

Energy requirements for

patient with cancer in bed
= BEE x 1.10 x 1.2

Activity Factor
1.2
1.3

ADA: Manual Of Clinical Dietetics. 5th ed. Chicago: American Dietetic Association; 1996
Long CL, et al. JPEN 1979;3:452-456

Hyperglycemia
Hypertriglyceridemia
Hypercapnia
Fatty liver
Hypophosphatemia, hypomagnesemia,
hypokalemia

Barton RG. Nutr Clin Pract 1994;9:127-139

Macronutrients during Stress

Macronutrientes during Stress

Carbohydrate

FAT

At least 100 g/day needed to prevent ketosis

Carbohydrate intake during stress should be
between 30%-40% of total calories
Glucose intake should not exceed
5 mg/kg/min

Barton RG. Nutr Clin Pract 1994;9:127-139

ASPEN Board of Directors. JPEN 2002; 26 Suppl 1:22SA

Macronutrients during Stress

Provide 20%-35% of total calories

Maximum recommendation for intravenous lipid
p
infusion: 1.0 -1.5 g/kg/day
Monitor triglyceride level to ensure adequate lipid
clearance

Barton RG. Nutr Clin Pract 1994;9:127-139

ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA

Determining Protein Requirements for

Hospitalized Patients

Protein

Requirements range from 1.2-2.0 g/kg/day during

stress
Comprise 20%-30% of total calories during stress

No Stress

Moderate Stress

Calorie:Nitrogen Ratio

> 150:1

150-100:1

Percent Potein / Total

Calories

< 15%
protein

15-20%
protein

Protein / kg Body Weight

0.8
g/kg/day

1.0-1.2 g/kg/day

Stress Level

Severe Stress
< 100:1
> 20%

protein

1.5-2.0
g/kg/day

Barton RG. Nutr Clin Pract 1994;9:127-139

ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA

Role of Arginine in Metabolic Stress

Role of Glutamine in Metabolic Stress

Considered conditionally essential for critical

patients
Depleted after trauma
Provides fuel for the cells of the immune system
and GI tract
Helps maintain or restore intestinal mucosal
integrity

Provides substrates to immune system

Increases nitrogen retention after metabolic stress
Improves wound healing in animal models
Stimulates secretion of growth hormone and is a
precursor for polyamines and nitric oxide
Not appropriate for septic or inflammatory patients.

Giving arginine to a septic patient is like putting gasoline on an already burning fire.
Smith RJ, et al. JPEN 1990;14(4 Suppl):94S-99S; Pastores SM, et al. Nutrition 1994;10:385-391
Calder PC. Clin Nutr 1994;13:2-8; Furst P. Eur J Clin Nutr 1994;48:607-616
Standen J, Bihari D. Curr Opin Clin Nutr Metab Care 2000;3:149-157

- B. Mizock, Medical Intensive Care Unit, Cook County Hospital, Chicago, IL

Barbul A. JPEN 1986;10:227-238; Barbul A, et al. J Surg Res 1980;29:228-235

Nutritional Assessment

Key Vitamins and Minerals

Vitamin A
Vitamin C
B Vitamins
Pyridoxine
Zinc
Vitamin E
Folic Acid,
Iron, B12

Medical

Wound healing and tissue repair

Collagen synthesis, wound healing
Metabolism, carbohydrate utilization
Essential for protein synthesis
Wound healing, immune function, protein
synthesis
Antioxidant
Required for synthesis and replacement of red
blood cells

Physical

examination
Biochemical

markers
Anthropometric
measures

Subjective Global Assessment

Tools for Nutritional Evaluation

Malnutrition Screening Tool (MST)1
Malnutrition Universal Screening Tool
(MUST)2
DETERMINE for screening and assessment3
Subjective Global Assessment (SGA)4

Patient-Generated SGA

(PG-SGA)5

Medical History
Weight change
9
9

9
9
9

5. Ottery FD. 1996. Nutrition 12:S15-S19.

6. Guigoz Y et al. 2002. Clin Geriatr Med 18:737-757.
7. Pablo A et al. 2003. Eur J Clin Nutr 57:824-831.

Past 6 months, 3 months

Past 2 weeks

Dietary intake compared

t usuall
to
GI symptoms
Functional capacity
9

Mini Nutritional Assessment (MNA)6

Nutritional Risk Index (NRI)7

1. Ferguson M et al. 1999. Nutrition 15:458-464.

2. www.bapen.org.uk/the-must.htm
3. www.aafp.org/Pre-Built/NSI_DETERMINE.pdf
4. Detsky A et al. 1987. JPEN 11:8-13.

history

No dysfunction
Working sub-optimally
Ambulatory
Bedridden

Metabolic needs of
disease

Physical Exam

Loss of subcutaneous fat

Muscle wasting

Ankle edema

Sacral edema

Ascites

A - Well Nourished
B - Moderately (or suspected
of being) malnourished

C - Severely Malnourished
Detsky A et al. 1987. JPEN 11:8-13.

Nutritional Assessment
Medical

Nutritional Assessment

Serum albumin
Serum transferrin
Serum prealbumin
Total
T l lymphocyte
l
h
count
Serum cholesterol
Nitrogen balance

history

Medical

Physical

examination
Biochemical

markers
Anthropometric
measures

history

Physical

examination
Biochemical
markers
Anthropometric
measures

Height
Weight
TSF
MAC

Nutrition Risk Assessment Form

BMI

nomogram

Underweight
Normal

<18.5
18.5
18.5 - 25

Overweight
Obese

25 - 30
>30

Evaluation of Weight Change

Time
1 week

Significant of Weight
Loss
1% to 2%

Severe Weight
Loss
> 2%

1 month
th

5%

>5%

3 months

7.5%

7.5%

6 months

10%

10%

Nutritional Requirements
Indirect

Calorimetry
formula with Long
modification

Harris-Benedict
9 Male:
M l

66
66.47
47 + (13.75
(13 75 x BW) + (5 x h
height)
i ht) (6.76 x Age) x AF x SF
9 Female: 655.1 + (9.56 x BW) + (1.85 x height) (4.67 x age) x AF x SF
Short

* Values charted are for percent weight change:

(usual weight - actual weight) x 100
Percent weight change =
usual weight

Method

9 Underweight:
9 Overweight:

ABW x 25 - 30 kcal/kg
IBW x 25 - 30 kcal/kg

Protein Requirements

Non-Stressed

- 0.8 gm/kg/day
Mildly
y Stressed - 1-1.2 g
gm/kg/day
g y
Severely Stressed - 1.5-2 gm/kg/day
Protein should comprise approximately
20% of the total calories during stress

Non-Protein Calories
Carbohydrate
Fats
9

NPC combinations
- acute stress: 70% carbo 30% fat
- usual: 60% carbo 40% fat
- infections: 50% carbo 50% fat
- pulmonary: 40% carbo 60% fat

Nutritional Interventions

Vitamin and Mineral Requirements

Micronutrient,

trace element, vitamin

and mineral requirements of
metabolically
t b li ll stressed
t
d patients
ti t are
elevated above normal
Give vitamin and mineral requirements
daily

Nutritional counseling
Oral supplementation
Enteral tube-feeding
Parenteral feeding

Enteral or Parenteral:
Selecting the Route of Delivery

If the g
gut works,
use it.

10

Clinical algorithm for N S

The rationale for early EN

of the gut stimulates GALT & MALT
resulting in enhanced immune response

Use

Early

feeding can trigger gut immunity and

thereby improve outcomes

Delay

or failure may promote a

proinflammatory state with disease
severity & morbidity
McClave, J Clin Gastro, Sept 2002

big

Enteral Formulas: Categories

Polymeric formulas
Commercial
Blenderized
Oligomeric formulas
Disease-specific formulas
Modular formulas (concentrated protein
and carbohydrate preparations)

Polymeric Formulas

small

part

Contain intact macronutrients and

require digestion:
I t t proteins
Intact
t i
Polysaccharides
Disaccharides
Polyunsaturated fatty acids (PUFA)
Medium-chain triglycerides (MCT)
Vitamins and minerals

part

Oligomeric Formulas

All in One Parenteral Formulas

Hydrolyzed macronutrients facilitate digestion

and absorption
Glucose polymers
Components
Amino acids
P l
Polyunsaturated
t t d fatty
f tt acids
id

Optimal utilisation of calories

Glutamine
Arginine
Peptides

Medium-chain triglycerides
Vitamins and minerals

Monosaccharides

Minimizes metabolic complications

- reduced volume load
- reduced CO2 production
- avoidance of hyperglycaemia
- less fat synthesis

Disaccharides
Also

called elemental, semi-elemental,

Permits peripheral administration

Rombeauhydrolyzed,
JL, Rolandelli RH, eds. Clinical
Enteral and Tubedefined
Feeding. 3rd ed. formula.
WB Saunders Company; 1997
orNutrition:
chemically

11

Access for Parenteral Nutrition

Central PN
Peripheral PN
Percutaneous
Any peripheral vein
Subclavian / Jugular
Aseptic technique required
Femoral
at all times
PIC line
Best removed after 48 72
Cutdown
hrs
Basilic vein
External jugular
Aseptic technique required

at all times

Take home message (2)

ACCURATE

ASSESSMENT

Accurate

calculation of calorie &

protein requirements

Strict

monitoring of actual feed

delivery is more effective than
overestimation of patient
requirements

Overfeeding

may be more harmful

than underfeeding !

Take home message (1)

ROUTINE

SCREENING

Assessment

of risk for nutritionrelated complications

High

index of suspicion

Consider

nature of illness and

over-all condition of patient
in the context of a second insult

Take home message (3)

ROUTE

OF DELIVERY
& preferential use of EN, combined
with PN whenever necessary

Early

MONITORING

IMPLEMENTATION
Monitor actual intake as an index
of success
Post-op: Monitor clinical parameters
Pre-op:

DOCUMENT

THE ENTIRE PROCESS !

What is our measure of success?

Surgical

nutrition will become an

established routine in patient care
Surgical nutrition will become
systematic and organized w/ multidisciplinary participation
Patient outcomes will improve
The objective proof will be
71
DOCUMENTATION

12