NUTRITION

● Nutrient – any substance obtained from food that contributes to mental or

physical health or growth

o Substances that are not synthesized in sufficient amounts in the body and
therefore must be supplied by the diet.

• ● All energy is provided by 3 classes of nutrients: 


o Fats

o Carbohydrates o Proteins 


• ● Vitamins, minerals and water are also required for good

health 

DIETARY REFERENCE INTAKES (DRI) 


• ● Estimates the amount of nutrients required to prevent

deficiencies and maintain optimal health and growth 


• ● Replace and expand on the RDA 


• ● Establishes upper limits on the consumption of 


some nutrients, and incorporate the role of nutrients in lifelong health 


ESTIMATED AVERAGE REQUIREMENT (EAR)

• ● The average daily nutrient intake level estimated to meet the

requirement of one half of the individuals in a particular life stage and
gender group 


• ● Not an effective estimate of nutrient adequacy in individuals

because it is a median requirement for a group; 


o 50% of individuals in a group fall below the requirement and 50% fall
above the requirement.

RECOMMENDED DIETARY ALLOWANCE (RDA)

● Average daily dietary intake level that is sufficient to meet the nutrient
requirements of nearly all healthy persons of a specific sex, age, life
stage, or physiologic condition (pregnant or lactating mothers)

● The nutrient-intake goal for planning diets of individuals

● Set to provide a margin of safety for most individuals

● Set at 2 standard deviations (SD) above the EAR

● RDA = EAR + 2SDEAR ADEQUATE INTAKE (AI)

● Based on estimates of nutrient intake by a group of apparently healthy

people that are assumed to be adequate

o Example: AI for infants - human milk recommendation is based on the

estimated daily mean nutrient supplied by human milk for healthy full-term
infants who are exclusively breastfed

TOLERABLE UPPER INTAKE LEVEL (UL)

● The highest average daily nutrient intake level that is likely to pose no
risk of adverse health effects to almost all individuals in the general
population.

o Useful due to increased availability of fortified food and increased use of

dietary supplements; applies to chronic daily use.

Figure 2. Observed level of nutrient intake

Figure 1. Subtypes of DRI of an individual

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RECOMMENDED ENERGY AND NUTRIENT INTAKES (RENI)

• ● Replaces the RDA to emphasize that the standards are in

terms of nutrients, and not foods or diets 


• ● Defined as levels of intakes of energy and nutrients which are

adequate for the maintenance of health and well-being of
nearly all healthy Filipinos 


• ● For most nutrients, these are equal to the average physiologic

requirement (AR), corrected for incomplete utilization or dietary
 nutrient bioavailability 


• ● For energy, the recommended intake is set at the estimated

average requirement of individuals in a group to prevent obesity 


across cell membranes, thermogenesis, energy necessary for growth and to

regain body mass (for patients with ongoing rehabilitation or after having
catabolic disease)

● During resting conditions, almost 60% of REE is spent by the heart, brain,
kidney and liver.

● Although these organs account only 5% of body weight.

1. Gender/sex - males have higher BMR than females

2. Weight - the heavier the weight, the higher the BMR

3. Age - REE decreases with the age of the subject, mostly due to mainly
the loss of mass

4. Body composition - individuals with higher percent of body fat have

lower BMR (muscle is more metabolically active than fat tissues)

5. Sleep – BMR is lower by 10% when a person is sleeping

6. Environment temperature - BMR is increased in a cold environment

because the body has to produce more heat to maintain normal body
temperature

7. Hormonal status - thyroid hormones, catecholamines and combined

secretion of glucagon, epinephrine and cortisol increase REE

8. Disease process - disease or trauma increases REE by 15 to 100%

9. Adaptation processes - prolonged starvation decreases REE

10. Drugs - sympathomimetic drugs increase REE; opiates, barbiturates,

sedatives, β-blockers, and muscular relaxants decrease REE

Note: Growing children spend REE > Adults

ESTIMATING REE
Males: REE = 900 + 10m Females: REE = 700 + 7m where, m is mass
in kilograms

● Calculated REE is adjusted for physical activity of an individual:

o sedentary adults: 30 kcal/kg/day o moderately active: 35 kcal/kg/day o

very active adults: 40 kcal/kg/day

METABOLIC RESPONSE TO FOOD

• ● Specific dynamic action of food or thermic effect of food 


• ● Diet-induced thermogenesis 


• ● Production of body heat increases as much as 


30% above the resting level during the 

digestion and absorption of food 


• ● Amounts to 5-10% of the total energy 


expenditure 


FACTORS AFFECTING RESTING ENERGY EXPENDITURE

Age/physiologic group Weight, Kg

Infants, mo birth- <6 ----------- 6

------------------
6 - <12 Children, yrs 9 -----------
------------------
1- 3 4- 6 7- 9 13 19 24

Age: Adolescents and Adults Males Females

 34 35
10 – 12 13- 15 16- 18
 50 49
19 - 49
 58 50
50 -64
 59 51
65 and over 59 51
59 51

Table 1. Age categories and reference weights

ENERGY BALANCE

• ● Our body is very effective in regulating the distribution of

metabolic fuel 


• ● We have the ability to shift from carbohydrate to fats and

protein as the main sources of energy coupled with the presence of
substantial reserve on body fat 


• ● It is possible to accommodate large variation in macronutrient

intake, energy intake and energy expenditure 


• ● The amount of fat stored in an adult of normal weight

commonly ranges from 6-20 kg 

COMPONENTS OF ENERGY EXPENDITURE 

1. Basal metabolic rate (BMR) or resting energy expenditure
(REE) 


2. Physical activity

3. Metabolic response to food (formerly

specific dynamic action)

RESTING ENERGY EXPENDITURE (REE)

● Energy required for indispensable homeostatic functions: breathing,

heart function, basic GI function, intermediary metabolism, maintaining of
ion gradients
2 of 18

FACTORSAFFECTINGENERGYREQUIREMENTS

● AGE

o Effect is primarily related to growth

and changing body size, particularly

from infancy to adolescence


o Infants, children, and adolescents need

more energy per unit body weight than

adults (since they are rapidly growing) o Older persons have lower energy
needs because of their decline in activity and

lower BMR

during fasting conditions (conserving

energy)

• ● DEE is conventionally assumed to meet 10% of 


your total energy expenditure. However, its value is dependent on the
thermic effect of specific substrates and on the rapidity of substrate
administration especially high rates of artificial nutrition administration
can lead to substantial increases in energy expenditure 

THERMIC EFFECT OF NUTRITION (TEN) 


• ● Defined as an increase in energy expenditure above basal

fasting level divided by the energy content of the food ingested,
usually expressed as a percentage of energy intake 


• ● Thermic effect of major energy substrates: 


o carbohydrates: 4-6% o lipids: 2-3%


o proteins: 20-40%

ACTIVITY INDUCED ENERGY EXPENDITURE (AEE)

 • ● Most variable part of energy expenditure 


• ● Dependent on physical activity during the day and also on

physical activity of a specific 

subject. 

Table 2. examples of energy expenditure through physical exercise, in
kcal/minute, for subjects of 60kg and 80kg 

● Energy for metabolic processes is produced by oxidation of energy
substrates (carbohydrates, lipids, and proteins) 

● During oxidation process, oxygen is consumed, and carbon dioxide,
water and nitrogen compounds (mainly urea) together with heat are
released 

● measured by: 


● GENDER

o Differences in body composition of men

and women largely account for differences in energy requirements per unit
body weight
o During adolescence, body composition changes radically, and by
adulthood, males have greater proportion of lean body mass, hence, higher
energy requirements

o REE differs by as much as 10% between men and women

● BODY SIZE

o A small/short person needs less energy

while a person with large/tall body requires proportionately more energy

• ● LEVEL OF PHYSICAL ACTIVITY


o Differences in physical activity 

represent the largest source of variability in energy requirements 

MEASURING ENERGY EXPENDITURE 


• ● End products of tissue metabolism: heat production,

carbon dioxide and water 


• ● Heat production - direct indicator of calorie requirement 


• ● Body - functions as a bomb calorimeter utilizing protein, fat

and carbohydrate for controlled oxidation 

DIET-INDUCED ENERGY EXPENDITURE 


• ● Energy expenditure increases: 


o after meal ingestion or

o during administration of artificial nutrition (parenteral or enteral) in

comparison with energy expenditure

o o

Direct calorimetry

Indirect calorimetry

DIRECT CALORIMETRY
METHODS FOR MEASUREMENT OF ENERGY EXPENDITURE

● Measures the dissipation of heat from the body ● Heat dissipation is

measured via an isothermal principle, a gradient-layer system

or a water-cooled garment.

● Total heat loss consists of sensible heat loss

and heat of water vaporization

Figure 3. Principle of direct calorimetry

3 of 18

INDIRECT CALORIMETRY
 • ● Measures the consumption of oxygen and the expiration of
carbon dioxide 


• ● Calculate heat production based on respiratory gases measure

over a unit of time 


o Oxygen consumption

o Carbon dioxide production


● It measures the heat produced by oxidative

processes as well as urinary nitrogen excretion o Because for every 1 gram

of nitrogen excreted, approximately 6L of oxygen is consumed and 4.8L of
carbon

dioxide are produced


● Using indirect calorimetry, we can measure:

o Oxygen consumption -VO2

o Carbon dioxide production- VCO2

• ● The amount of heat being produced can be calculated from the

ratio of the carbon dioxide 

expired to the oxygen inhaled 


• ● This ratio is known as the Respiratory Quotient 


(RQ) 


● Approximately 4.83 kcal/L O2 consumed at an average RQ of 0.82 (diet

consists of 40% carbs & 60% fat.

● RQ < 0.70 – fat converted to carbohydrate ● RQ = 1 – carbohydrate is

being oxidized

● RQ > 1.0 – carbohydrate converted to fat

RQ – CLINICAL PRACTICE

● RQ < 0.8 – patient maybe underfed


● RQ < 0.7 – starvation or eating a low-
carbohydrate or high-alcohol diet

● RQ > 1 – suggests lipogenesis is occurring (fat

synthesis)

ESTIMATING TOTAL ENERGY EXPENDITURE

• ● Estimating rather than measuring BMR or REE has been the

practice since 1925. 


• ● Estimations have been based on body surface area, body

weight, and/or calculations from equations that take into account the
person’s gender, age, weight and height. 

CALCULATING BASAL ENERGY EXPENDITURE 


1. HARRIS-BENEDICT EQUATION (MUST KNOW!)

• ● gender, weight (kg), height (cm), age (years) 


• ● used to compute for Basal Metabolic Rate (BMR) which is also

known as Resting Energy Expenditure (REE) 

MEN 

BMR =66.47+(13.75 x W)+(5 x H)–(6.76 x A) 

WOMEN 

BMR=655.1+(9.56 x W)+(1.85 x H)-(4.67 x A) 

Examples: 

1. 25 year old male; 5’7”; 70kg

BMR=66.47+(13.75 x 70)+(5 x 170.18)–(6.76 x 25) 

BMR=1713.12 

2. 25 year old female; 5’7”; 65kg

BMR=655.1+(9.56 x 65)+(1.85 x 170.18)-(4.67 x 25) 

BMR=1474.58 

2 METHODS OF ESTIMATING BMR 

1. Based on body weight raised to the power of three-fourths,
or 0.75 


0.75
○ Where (W) weight is in Kg BMR (kcal/day) = W x W 2. Reasonable
estimate of kilocalories

o Men=1kcal
o Women = 0.9 kcal

BMR (kcal/day) = Estimate x W(kg) x 24hrs

E.g. Estimate BMR of a 65 kg woman 1. BMR=65x650.75=65x22.89

= 1,487 kcal/day

Figure 4. Ventilated canopy

Figure 5. Principle of indirect calorimetry

RESPIRATORY QUOTIENT

RQ = volume of CO2 produced volume of O2 consumed

• ● C6H12O6 + 602 6CO2 5H2O + Energy (880 kcal) glucose (MW =

162) 


• ● C51H98O6 + 72.5O2 51CO2 + 4H2O + Energy (7557 kcal)

tripalmitin (MW = 806) 

RQ – AVERAGE SITUATION 


• ● RQ for an ordinary mixed diet consisting of the three energy-

producing nutrients is considered to be at 0.85 


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2. BMR=0.9kcalx65kgx24hrs = 1,404 kcal/day

*both estimates are near the calculated BMR in example 2 found under BMR
calculation using Harris- Benedict equation.

ESTIMATING TOTAL ENERGY EXPENDITURE

● Once basal or resting energy needs have been determined, energy needs
for diet-induced thermogenesis, and for physical activity must be added to
the BMR to estimate total energy needs.

Figure 6. Percentage of energy expenditure

ADULTS

TER = BMR (1kcal/Kg/hr x 24hrs) + Physical activity(% above

basal)

*Note: if patient is overweight/obese (25 and above BMI), ideal body weight (IBW)
should be used in computing for the BMR to be used in TER computation.

PREGNANT WOMEN

TER/day = Normal requirement + 300Cals

LACTATING WOMEN
TER/day = Normal requirement + 500 Cals

ACTIVITIES – METHODS (Cooper et. al)

• ● (Physical Activity or % above basal) 


• ● Bed Rest – 10% 


• ● Sedentary – 30% 

o Secretary, clerk typist, administrator, cashier, bank teller 


• ● Light – 50%

o Teacher, nurse, student, lab tech, 

housewife with maids 


• ● Moderate – 75% 

o Vendor, mechanic, jeepney and car driver, housewife without maids 


• ● Heavy – 100%

o Farmer, laborer, cargador, coal miner, 


*Again, if patient is overweight/obese (25 and above BMI), physical activity

percentage is to be disregarded. Use instead values within the range of 25-30.

DISTRIBUTION OF TER

• ● Method 1: By Percentage Distribution 1. Carbohydrates:

50-70%

2. Protein: 

Infants: 10% 

Adults:10-12% 3. Fats: 

Normal adults/ moderately active: 20- 25%

Children/adolescents/very active individuals: 30-35% 


• ● Weight loss: decrease calorie intake by 500 per day 


o 5% in 3 months o 10% in 6 months

*Note: You can decide what percentages to use as long as: (1) it is within
the specified range, and (2) CHO + CHON + Fats = 100%

TER AND TER DISTRIBUTION EXAMPLES

1. 25 year old male; 5’7”; 70 kg student TER = BMR + %activity above

basal TER= 1713.12 + 50%(1713.12)

TER = 1713.12 + 856.56

TER = 2569.68

CHO: 2570 x 0.6 = 1542 cal/4 = 386 gms CHON: 2570 x 0.12 = 308 cal/4
= 77 gms Fats: 2570 x 0.28 = 720 cal/9 = 80gms *Prescription: 2570
calories, C386 P77 F80

2. 25 year old female; 5’7”; 65kg; housewife without maids


BMR: 1474.58

TER=1474.58 + 75%(1474.58)

TER = 2580.51

CHO: 2581 x 0.65 = 1678 cal/4 = 420 gms CHON: 2581 x 0.10 = 258 cal/4
= 65 gms Fats: 2581 x 0.25 = 645 cal/9 = 72 gms *Prescription: 2581
Calories = C420 P65 F72

*NOTE: These were lifted directly from the lecture ppt, however
things went really confusing.. just please refer to basic nutrition
practice test (Cases A-E) at the end of this trans for the
computation.

• ● Everyone should have nutritional assessment 


• ● Ideally, all hospital admissions should undergo nutrition

screening; esp. at first contact with a 

patient 


• ● A simple, quick, and general procedure used 


by any medical staff 


• ● Anthropometric Measurement - taking 


ESTIMATING TOTAL ENERGY REQUIREMENT

MUST KNOW

NUTRITIONAL ASSESSMENT TECHNIQUES SCREENING

fisherman, heavy equipment operator

proper height and weight

5 of 18

ESTIMATING IDEAL BODY WEIGHT (IBW)

INFANTS: 1st SIX MONTHS

DBW(gms)= Birth wt(gms)+(age in mos x 600) ● BABY: 7 – 12

MONTHS
DBW(gms)= birth wt(gms)+(age in mosx500)

DBW (kg) = (age in mons) + 3 2

CHILDREN

DBW (kg)= (no. of yrs x 2) + 8

ADULTS

1. Body Mass Index-based formula 2. Tannhauser’s Method

● BODY MASS INDEX


o Evaluates weight relative to height

o Replaced percentage ideal body weight

as criterion for assessing obesity


o Correlates significantly with body fat,

morbidity and mortality ● Calculating body mass index:

o Calculated as weight/height2 in kg/m2

o Weight = kg

o Height = meters squared


● Example: 25 year old male; 5’7”; 70kg

BMI = 24.2

Figure 7. BMI chart

• ● Measure height in centimeters 


• ● Deduct from this the factor, 100, and the 


answer is the DBW in kg 


• ● The DBW obtained applies to Filipino stature by taking of 10% 


Convert height to cm – 100 = X less 10% 

● Example: 

o Height: 5’7” = 67”

o 67inx2.54cm=170.18cm–100= 70.18kg

o 70.18kg – 7.018 (10% of 70.18kg) = 63.16kg

NUTRITIONAL ASSESSMENT

Screening should be performed within the first

24-48 hours after the first contact and thereafter at regular intervals.
Patients identified as at risk need to undergo nutritional

assessment.

ASSESSING OBESITY

(MUST KNOW!)
o

Figure 8. Nutritional Screening and Assessment

● Nutritional Assessment:

1. Should be done in detail

2. In those patients found on screening to be at risk or when metabolic or
functional problems prevent a standard plan being carried out

3. Nutritional assessment also provides the basis for the formal diagnosis of
malnutrition

NUTRITIONAL SCREENING TOOLS

1. Birmingham Nutrition Score


2. Malnutrition Screening Tool

3. Malnutrition Universal Screening Tool

4. Maastricht Index

5. Nutrition Risk Classification

6. Nutrition Risk Index

7. Nutrition Risk Screening 2002

8. Prognostic Inflammatory and Nutritional Index 9. Prognostic Nutrition
Index

10. Simple Screening Tool

11. Short Nutrition Assessment Questionnaire

METHOD OF SCREENING

● Several validated screening tools are available and recommended by the

European Society for Clinical Nutrition and Metabolism (ESPEN)

● The screening tools address several basic questions:

o Recent weight loss


o Current body mass index o Recent food intake

o Disease severity

● Community: Malnutrition Universal Screening Tool (MUST)

● Hospital: Nutritional Risk Screening (NRS) ● Elderly: Mini Nutritional

Assessment (MNA)

1. Subjective Global Assessment (SGA) 2. Patient Generated Assessment

(SGA)

TANNHAUSER’S METHOD (IDEAL BODY WEIGHT; IBW)

(MUST KNOW!)

6 of 18

Absent Absent
Normal nutritional status
Normal nutritional requirements
Score 0 Score 0
Wt loss >5% in 3 months

Hip fracture

Mild or Mild
Chronic patients, in particular with acute
complications: cirrhosis, COPD

Score 1 Food intake below 50-75% of Score 1 Chronic hemodialysis, diabetes, oncology
normal requirement in preceding
week
 Wt loss >5% in 2 months

or

BMI 18.5 - 20.5 + impaired
Modera te Modera te
general condition Major abdominal surgery Stroke

Severe pneumonia, hematologic malignancy
Score 2 Score 2
or

Food intake 25- 50% of normal
requirement in preceding week
Wt loss >5% in 1 months
(>15% in 3 months)

or

Severe Severe Head injury


BMI < 18.5 + impaired general
Bone marrow transplantation Intensive care
condition

Score 3 Score 3 patients (APACHE>10)
or

Food intake 0-25% of normal

requirement in preceding week

Score: +
Score: =Total score:

Age if ≥ 70 years: add 1 to total score above = age-adjusted total score:

Score ≥ 3: the patient is nutritionally at-risk and a nutritional care plan is initiated. Score < 3: weekly re-screening of the patient. If
the patient is (e.g.) scheduled for a major operation, a preventative nutritional care plan is considered to try to avoid the associated
risk.

Figure 9. Malnutrition universal screening tool for adults

Initial screening I
Yes No
1 Is BMI < 20.5?
2 Has the patient lost weight within the last 3 months?
Has the patient had a reduced dietary intake in the last
3
week?
4 Is the patient severely ill? (e.g. in intensive therapy)
Yes: If the answer is 'Yes' to any question, the final screening is performed.

No: If the answer is 'No' to all questions, the patient is re- screened at weekly
intervals. If the patient is (e.g.) scheduled for a major operation, a preventative
nutritional care plan is considered to try to avoid the associated risk.
Table 3. Nutritional Risk Screening (NRS 2002); Initial screening questions

Table 4. Nutritional Risk Screening (NRS 2002); Final screening

• A Has food intake declined over the 


past 3 months due to loss of appetite digestive problems, chewing or
swallowing difficulties? 

0 = severe loss of appetite

1 = moderate loss of appetite 

2 = no loss of appetite 


• B Weight loss during last 


months? 

0 = weight loss greater than 3 kg

1 = does not know 2 = weight loss between 1 and 3 kg 3 = no weight loss 


Final screening II

Severity of disease (≈ increase

Impaired nutritional in requirements)
status

7 of 18

Mobility?

0 = bed or chair bound


1 = able to get out of bed/chair but does not go out

2 = goes out
D

Has suffered physical stress or acute disease in the past 3 months?


0 = yes

2 = no

Neuropsychologic al problems?

0 = severe dementia or depression

1 = mild dementia 2 = no psychological problems

Body Mass Index (BMI) [weight in kg]/[height in m]2?

0 = BMI less than 19


1 = BMI 19 to less than 21

2 = BMI 21 to less than 23


3 = BMI 23 or greater
Screening score (subtotal max. 14 points)

12 points or greater

Normal - not at risk

-> no need to complement assessment

11 points or below

Possible malnutrition

-> continue assessment

SOFA <6
0
6 - < 10 1
> 10 2
Co-morbidities 0-1 0
2+ 1
Days from hospital to ICU 0-<1 0
1+ 1
IL-6 0 - < 400 0
400 + 1

Table 5. Mini Nutritional Assessment

Table 6. Nutric Scoring System

NUTRITIONAL ASSESSMENT

● History: Factors leading to malnutrition o Pain

o Weight loss

o Appetite

o Diet history

o Medical and drug history

o Gastrointestinal symptoms (diarrhea,

constipation, nausea, vomiting) o Fever

o Symptoms of psychiatric illness (depression, anorexia nervosa)

● Clinical findings

o Temperature

o Pulse rate

o Blood pressure

o Nutrient losses from wounds, fistulae,

etc

● Functional assessment o Muscle strength

o Mental and physical dysfunction o Mental scoring system


o Mood status

● Energy expenditure: Laboratory Tests o Haematological screen

o Biochemical parameters (urea, creatine, liver function tests)

o Quantifying inflammation and disease severity

o Plasma protein levels (transthyretin, transferrin)

o Plasma changes in minerals (sodium, potassium, calcium, magnesium,

phosphorus, zinc, iron; plasma levels of vitamins)

● Fluid balance

o There are many methods and indices

which are based on the above assessment methods. Their

 Nutric scoring system
Variables in Nutric score Nutric scoring system
Range
Points
Age < 50 0
50 - < 75 1
> 75 2
APACHE II < 15 0
15 -20 1
20 - 28 2
> 28 3

8 of 18

interpretation and correlation however, can still be problematic

NUTRITIONAL ASSESSMENT

1. History 


2. Physical Examination 


3. Body composition

• BMI 


• Bedside anthropometric measurement 


• Mid arm circumference 


• Triceps skin fold testing 


• Creatinine height index 


• Biometric impeded analysis 


 • DEXA, MRI, CT Scan 


• Nitrogen Balance 


4. Measurement of inflammation 


5. Measurement of function

• Muscle strength 


• Cognitive function 


• Immune function 


• Quality of life assessment 


NUTRITION CARE PLAN 


• ● Calories 


• ● Protein 


• ● Electrolytes 


• ● Vitamins 


• ● Trace elements 


• ● Immunonutrients 


• ● Formulation 

 • ● Access 


• ● Delivery method 


• ● Monitoring 

NUTRITIONAL REQUIREMENTS 


• ● Components of Nutrition: 


o Macronutrients: carbohydrates,

proteins, fats

o Micronutrients: vitamins, minerals,

trace elements

o Fluids and electrolytes

ESSENTIAL NUTRIENT REQUIREMENTS

1. Water 


2. Energy 


3. Protein 


4. Fat 


5. Carbohydrate 


6. Vitamins 


7. Minerals and trace elements 


 8. Antioxidants 


9. Phytochemical 

WATER 


• ● Fever increases water losses by approximately 200 mL/d per

°C 


• ● Diarrheal losses vary, but may be as great as 5 L/d in severe

diarrhea. 


• ● Heavy sweating and vomiting also increase water losses. 


● Infants have high requirements for water because of their large ratio of
surface area to volume, the limited capacity of the immature kidney to
handle high renal solute loads, and their inability to communicate their
thirst.

● Increased water needs during pregnancy and lactation

o During lactation, milk production increases water requirements so that

approximately 1000 mL/d of additional water is needed, or 1 mL for each mL
of milk produced.

● Special attention must be paid to the water needs of the elderly

o have reduced total body water and blunted thirst sensation

o are more likely to be taking medications such as diuretics

VITAMINS

● Vitamins are an essential part of all diets, both in normal individuals

and in those requiring nutritional support

● For patients requiring intravenous nutrition should receive vitamins from

the beginning of their intravenous nutrition (IV)

● Requirements in disease are often greater than in health, to cope with

increased metabolic requirements and increased losses
● Optimizing intake of vitamins in nutritional support is difficult since
laboratory tests are rarely sufficient sensitive and specific in patients with an
inflammatory response

MINERALS AND TRACE ELEMENTS

● Defining the optimal intake of micronutrients is far from ideal

● Provision of micronutrients to ensure the best possible tissue function

remains poorly defined

● Possible methods of trying to optimize provision in relation to function can

be considered with respect to the antioxidant system, and also to the
immune system

ANTIOXIDANTS

● Dietary antioxidants are found particularly in the form of vitamins A, C

and E, and as the trace element selenium

● Oxidative stress can lead to a variety of diseases including cancer,

cardiovascular disease, non-alcoholic fatty liver disease, dementia and
macular degeneration

● Antioxidant supplementation may decrease risk and improve disease

outcomes especially in critically ill patients

● Consumption of dietary antioxidants can be beneficial, pharmacological

doses of supplemental antioxidants in the healthy can occasionally have
deleterious effects

● Antioxidants are important to reduce the burden of oxidative stress on

the body.

o Antioxidants are ingested in the diet and can also be produced

endogenously in the body.

9 of 18

o Dietary antioxidants are predominantly in the form of Vitamin A, C, E and

selenium
● Oxidative damage to DNA, proteins and lipids can lead to a wide variety
of diseases including cancer, CVD, NAFLD, lung disease, dementia, cataract,
and macular degeneration

o important to maintain intake of dietary antioxidants to minimize disease

risk

● Meta-analyses- conflicting results


o Generally is unlikely to cause harmful effects and may occasionally be
beneficial provided appropriate dosage is administered (a few exceptions:
carotenoids and lung cancer; vitamin E

and lung cancer)

● Beneficial effects

o Selenium in cancer, antioxidant

supplementation in ICU patients, vitamin E in CVD, NAFLD, Alzheimer’s,

dementia; antioxidants in asthma and in cataract, macular degeneration

PHYTOCHEMICALS

• ● The major action in plants: protection against ROS and

insects 


• ● The data of the studies do not justify a recommendation for

the use of single phytochemical 


o A general recommendation can be made to increase fruit and vegetable

intake as these are the major sources and will help to increase supply

• ● Low intake of fruits and vegetables are at risk of oxidative

stress. Specifically, polyphenols, involved in the regulation of
inflammatory response are of great importance 


• ● More than 900 phytochemicals (plant derived bioactive

compounds) have been identified and further 900 or more might exist 


• ● The major action of phytochemicals: antioxidative activity 


 • ● Consequently, their frequent intake (via 5 a day) is related to
a decreased risk of developing degenerative diseases, cancer) 


• ● Some phytochemicals how an anti- inflammatory potential

which makes them possible future candidates for clinical nutrition 

ENERGY 


• ● Required to sustain the body’s various functions including

respiration, circulation, physical work, and maintenance of core body
temperature 


• ● For weight to remain stable, energy intake must match energy

output 


Figure 9. Energy available from major food stuff

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●●●

CARBOHYDRATES

Provide 50% to 60% of total calories Necessary to maintain protein

anabolism Produces 4kcal/g by mouth or enterally and 3.4 kcal/g
intravenously

FAT RECOMMENDATIONS

Source of energy and essential fatty acids o Linoleic acid: 2 to 7 g/day

Provide 20% to 30% of total calories o 1 g/kg/day

In special disease management

■■

45+% of total calories from fat may be beneficial

Glycemic control

Reduction of CO2 production

DETERMINING PROTEIN REQUIREMENTS

● Body weight

● Age

● Type of protein

● Daily requirements:

o Healthy: 0.8 to 1.0 g/kg/day


o Stressed state: 1.0 to 2.0 g/kg/day

depending on condition

AMINO ACIDS

● Essential (PVT TIM HLL always argues, never tires [always Arg never Tyr])

o Leucine

o Lysine

o Valine

o Threonine

o Isoleucine

o Phenylalanine o Methionine

o Histidine

o Tryptophan

● Non-Essential o Alanine

o Tyrosine

o Aspartic Acid o Glutamic Acid o Cysteine

o Glycine

o Serine

o Proline
● Conditionally Essential o Glutamine

o Arginine

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VITAMINS

• Fat Soluble Vitamins (A, D, E, K) 


• Water Soluble Vitamins 


o B1 – thiamine

o B2 – riboflavin

o B3 – niacin

o B5 – pantothenic acid o B6 – pyridoxine

o B7 – biotin

o B9 – folic acid

o B12 - cobalamins o Vitamin 6

MINERALS

1. Sodium 


2. Potassium 


3. Chloride 


4. Calcium 


5. Phosphorus 


6. Magnesium 


7. Zinc 

 8. Copper 


9. Chromium 


10. Manganese 


11. Selenium 


12. Iodine 


13. Iron 


DISTRIBUTION OF TER INTO CHO, CHON, FATS

• ● Carbohydrates: 50-70%; average: 60% 


• ● Proteins: 10-15% 


• ● Fats: 25-30% 


Figure 10 Idaho Plate Method used to visualize food portions for patients

BALANCE LOW CALORIE DIET

● For Obese patients


Men = 1200 – 1600 calories

Women = 1000 – 1200 calories


● Daily intake of 500 – 750 calories for 1- 1 1⁄2

pound weight loss (recommended by NHLBI) ● Based on the computation of

your daily

energy requirement i.e. computing on your daily allowable calorie need

based on your activity. You can use here the manipulation of the BMI
computation:
● Ideal body weight in kg = ideal BMI range (20-21) x height in meter2

● Then the ideal body weight is multiplied on the type of energy expenditure
(sedentary 26-28 calories, active 30, more active 32.) and the product will
give you the total daily caloric requirement where you will subtract your
500-1000 calories.

● Example: A 1.6m man with a sedentary lifestyle his total daily caloric
requirement to maintain a normal BMI of 21 is 1505 calories base on 21 x
1.6 m x 1.6 m x 28.

● Based on 55% Carbohydrates and then divided the rest of the calories to
around 45% to proteins and fats.

LIPIDS

● Functions:

o Concentrated sour