nutrition exam 4

Energy and nutrient needs vary with

Weight Height Age Gender Metabolic rate Activity--Type/ Frequency/ Intensity/ Duration of training and performance

Vegans deficiency problem with

Use of complementary proteins At risk for calcium, zinc, iron, vitamin B12 deficiency Often more attentive attitude, behaviors to diet, thus, healthy intakes

The metabolic response to critical illness/injury is different/similar simple or uncomplicated starvation.

VERY different from

Athletes that consume high protein, risk compromising their ________- which may impact their ability to train or compete at their peak levels.

carbohydrate status

adaptive state of starvation, protein ________ is reduced, and hepatic gluconeogenesis ______.

catabolism decreases

Body composition can be divided into a ___ and a ___

fat fat-free component or LBM

Changes in body composition after critical illness or major surgery Catabolism leads to a decrease in __________ Body weight may __________ because of _____

fat mass and skeletal muscle mass paradoxically increase because of expansion of extracellular fluid space

The rate of growth slows after the ___ year of life

first

albumin and prealbumin are only good if you are if you are not, use

not undergoing inflammation BUN creatinin

Proinflammatory/prothrombotic state elevated C-reactive protein endothelial dysfunction hyperfibrinogenemia increased platelet aggregation increased levels of plasminogen activator inhibitor 1 elevated uric acid levels microalbuminuria shift toward small, dense particles of low-density lipoprotein (LDL) cholesterol

obesity

5 kcal/g, -1 kcal/g for deamination - thus, 4 kcal/g

protien

Generally when using the standard energy calculations - they will give you a ____ amount which will provide adequate calories; so one does not usually have to calculate non-protein calories in most stable patients.

target

A repeated measurement should be considered if an RQ value is outside the range of CARBOHYDRATES ARELINKED TO THIS

0.70 to 1.0.

3 processes of ATP production:

1)glycolysis 2)TCA cycle 3)oxidative phosphorylation. (#2 & #3 0ccur in the mitochondria

Calculation of daily water requirements Method 1 <10kg 11-20 Kg >20 kg RDA Method

16 to 30 years, active 40 ml/kg 20 to 55 years 35 ml/kg 56 to 75 years 30 ml/kg >75 years 25 m/kg

Nutrition Assessments - ABCD (*E3)

Anthropometric--Height, weight, circumference, body composition Biochemical--Blood, urine, hair analysis Clinical --Hair loss, thirsty, skin pinch, discoloration Diet (compare and contrast)--24 hour recall, 3 day food record, Food Frequency Questionnaire (FFQ) Economics, Emotions, and Education

A measurement or description of the physical dimensions and properties of the body; typically, used on upper and lower limbs, neck, and trunk. Valuable measurements include: height, weight, girth measurements, and skinfold thickness. In pediatric settings: head circumference, length are also used.

Anthropometrics -

The study of objective measurable physical variables in humans, which impacts on architecture, industrial design and ergonomics.

Anthropometry-

helps to identify acute hypermetabolic periods NON-specific markers of inflammation

CRP - C-reactive protein---

are one of 2 main fuels used for sports activity. The first source of glucose for the exercising muscle is its own glycogen store. Next is glycogenolysis and gluconeogenesis -- both occur in the liver - maintain the glucose supply. During exercise that exceeds 90 minutes - like marathon running/ competitive swimming -- when muscle glycogen stores drop to very low levels --that is when they " hit the wall". Glycogen depletion may also be a gradual process occurring over repeated days of heavy training or after several interval sets at maximum oxygen consumption. Glycogen breakdown exceeds replacement.

Carbohydrates

Often physically active people, including high level athletes get their nutrition information from unreliable sources such as:

Coaches, peers, trainers, the media, and the internet. Information on the efficacy and safety of many of these products used by athletes is limited or even absent! Note - many supplemental sports food products, shakes, bars, drinks may contain prohibited substances on the World Anti-Doping Agency's (WADA) list. (table 23 -6, p 447, in Krause)

- During growth and in some disease states, the need for several AA increase because synthesis cannot meet metabolic need.

Conditionally essential*

enhances skeletal muscle catabolism, and increased hepatic use of AA's for gluconeogenesis, glycogenlysis, and acute-phase protein synthesis. Branched chain AA's (BCAAs) our oxidized from muscle as a source of energy for muscle. {glucose alanine cycle and muscle glutamine synthesis}

Cortisol

regulatory hormones - are involved in accelerated proteolysis.

Counter -

Metabolic stress typically leads to an altered hormonal state - increase flow of macronutrients but use of carbohydrates, protein, fat and oxygen.

Counter -regulatory hormones - are involved in accelerated proteolysis. Glucagon promotes gluconeogenesis, AA uptake, ureagenesis, and protein catabolism. There is elevation in the ratio of glucagon to insulin. Cortisol enhances skeletal muscle catabolism, and increased hepatic use of AA's for gluconeogenesis, glycogenlysis, and acute-phase protein synthesis. Branched chain AA's (BCAAs) our oxidized from muscle as a source of energy for muscle. {glucose alanine cycle and muscle glutamine synthesis} Acute phase proteins: --. Rapid loss of LBM, increased net nitrogen balance. Lipid metabolism is altered - increased lipolysis -> increase in Free fatty acids Cytokines (proinflammatory proteins) play a role in the regulation of the injury response

play a role in the regulation of the injury response

Cytokines (proinflammatory proteins)

The Mifflin-St Jeor Equation, 5% more accurate (1990)-not for critically ill patients use the Penn State equation for patients <60 yr.. For critically ill patient if you do not have access to indirect calorimetry

Estimating Energy Needs/predictive equations that dimmucci ward suggestd

spine trauma energy--Avoidance of over feeding is IMPORTANT. _________ which may prolong weaning from the vent.

Excess calories -> hyperglycemia, hepatic steatosis, excess CO2 production

____requires essential elements from food to fuel muscle contractions, build new tissue, preserve lean muscle mass, optimize skeletal structure, repair existing cells maximize oxygen transport, maintain fluid and electrolyte status and more.

Exercise

following a ___ meal, Fat oxidation significantly higher at rest and during exercise Less carbohydrate to glycogen stores Yet, better preservation of glycogen during exercise

Following a low GI meal:

promotes gluconeogenesis, AA uptake, ureagenesis, and protein catabolism. There is elevation in the ratio of glucagon to insulin.

Glucagon

MNT Goal spine trauma

Goal = is to oppose the hypercatabolism and hypermetabolism associated with inflammation. Energy - Indirect calorimetery is ideal to get an estimate of energy needs but is often unavailable. may use 25 to 30kcal/kg/day using actual body wt. or better yet use the Penn State equation for patients <60 yr.. * with a hypocaloric and high protein is suggested in some patients -"permissive underfeeding" (14kcal/kg) in obese critically ill pts, achieves net protein anabolism and minimizes complications from overfeeding. Avoidance of over feeding is IMPORTANT. Excess calories -> hyperglycemia, hepatic steatosis, excess CO2 production which may prolong weaning from the vent.

Obesity - Defined Grade 1:BMI Grade 2: BMI Grade 3: BMI Grade 4: BMI Grade 5: BMI

Grade 1:BMI 30-34.9 kg/m2 Grade 2: BMI 35-39.9 kg/m2 Grade 3: BMI 40 kg/m2 Grade 4: BMI 50 kg/m2 Grade 5: BMI 60 kg/m2 Circulation. 2009; 120: 86 -95

______ Energy needs for disease conditions, i.e., Cystic fibrosis, _____% increase over RDA

Hi 120-150 69% fail to meet "E" needs, 72% fail to meet "E" and protein

There is an ongoing homeostatic drive to preserve ____ as a self-protective process

LBM-- Lean body mass

____ contains all of the body's protein content and water content, making up 75% of the normal body weight. Every protein molecule has a role in maintaining body homeostasis.

LBM-- lean body muscle

- increased lipolysis -> increase in Free fatty acids

Lipid metabolism is altered

Example: 200 lb. male 1lb +2.2kg 200lb/2.2 = 90.9 kg 90.9kg x 0.8 = 72.7g protein 1 oz. of meat is 7g protein 72.7/7 = ~10.4 oz. Protein is 4 kcal/gram 72.7 g x 4 kcal = ~291 kcal

Note : this calorie total assumes no fat was consumed with the protein or was in the protein source

___ - another macronutrient, important but no E value! ___ another form of malnutrition Most common cause of hospitalization among elderly! Young children poor thirst, temp regulation Athletes (including Nascar drivers) hydration/elimination a concern! Reduces blood volume

Water Dehydration

___ g protein/kg/day, healthy adults

0.8

BMI used as parameter BMI = __ "Normal" = ___ "Overweight" = ___ Obesity is defined as BMI ___

BMI used as parameter BMI = kg/m2 "Normal" = 18.5-24.9 "Overweight" = 25-29.9 Obesity is defined as BMI 30 kg/m2

Fat - most concentrated fuel

Body carbohydrate stores (glycogen, 2,600 kcal) Body fat stores 3,500 kcal/lb. of fat 74 kg ( 163 lb.) athlete, 10% body fat - 57,000 kcal Fat oxidation best for low-intensity, will compromise high intensity bouts

Plasma levels of omega 3 fatty acids are inversely associated with the inflammatory markers: CRP, IL-6, fibrinogen, and homocysteine. The Lp-PLA2 is measured by the PLAC test * It is well accepted that lifestyle and diet modification is the backbone of cardiovascular disease prevention.

Heart disease

___ is considered and essential amino acid for infants.

Histidine

Excess calories cause Nutritional management of Hypermetabolic stress:

Hyperglycemia Diuresis - complicates fluid/electrolyte balance Hepatic steatosis (fatty liver) Excess CO2 production Exacerbate respiratory insufficiency Prolong weaning from mechanical ventilation

- protein deficiency you will see often in children ascites

Kwashiorkor

protein and energy deficiency

Marasmus -

Critically ill patients consider one of the following as they have the best prediction accuracy of equations studied: ADA's Evidence Analysis Library -if predictive equations are needed for the non-obese,

Pen state, 2003a ( 79%) Swinamer (55%) Ireton-Jones Equation ( 1992) for estimated energy expenditure in ventilator-dependent patients.

are often corrected by surgical intervention.

Subdural hematomas -

When considering protein requirements - it is important also to consider

caloric need.

Bilateral oedema

clinical sign of severe wasting

In the USA trauma is the leading cause of death in persons up to 44 years of age and greater than half of these deaths are due to ___________. With peak frequency between 15 -24 years of age.

head injuries

healing vs nonhealing wound metabolic states

healing wound - high anabolism -decreased catabolism nonhealing wound -high catabolism -low anabolism

I see a very ill patient, or a long standing bedridden patient with a low Crt... or low BUN it is a red flag to me to consider the likelihood of loss of

lean muscle

organ is 50% fat

lungs

Nutritional management of Hypermetabolic stress

minimize catabolism meet protine energy and micronutrient needs establish and maintain fluid and electrolyte balance meed protien energy and micronutrient needs plan nutrition therapy oral enternal, parenternal nutrition

does pem affect the next generation

yes-- famine survivors have obeses children

General Goals of Medical Nutrition Therapy

--Maintain biochemical equilibrium for the affected pathway --Provide adequate nutrients to support typical growth and development --Support social and emotional development

developed a series of action (ACT) sheets and confirmatory algorithms for disorders identified by newborn screening. Other groups who have recommendations: WHO, March of Dimes, and Massachusetts New Born Screening Advisory committee.

American College of Medical Genetics (ACMG)

Summary of protein absorption

Absorption by enterocyte systems Some passive, some paracellular Most Na dependent carriers Competitive transport between AA BCAA, EAA and Neutral absorbed fastest Dietary supplements of single AA problematic Impairs absorption of other AA, imbalance Peptides absorb faster than free AA N assimilation faster with food protein vs DS protein

it is found almost exclusively in the muscle tissue. Used along with Bun it is used to assess kidney function.

Creatinine-

Indispensable amino acids- we must get from diet

Essential

___ mass comprises about 25% of body composition The ___ compartment is a calorie reservoir where day-to-day excess calories are stored or removed if needed.

Fat fat

What maintains lean mass?

Intense genetic drive to maintain essential protein stores Anabolic hormones that stimulate protein synthesis Resistance exercise Adequate protein intake to meet the demands

Protein deficiency Impact on stature, lean body mass, fluid balance

Intracellular space Extracellular space Intravascular fluid Interstitial fluid Albumin

Lactovegetarian deficiency problem with

Iron (drinks milk)

Lacto-ovo-vegetarian deficiency problem with

Iron (eats eggs and milk)

Dispensable amino acids

Nonessential

Those diagnosed and treated early have less neurologic damage Those with mental retardation may have hyperactivity or self-abuse Recommend continuing low-phenylalanine diet throughout life Poor control associated with reduction in intelligence

PKU

Nutrition Interventions for Genetic Metabolic Disorders. Work with a _____ and your genetic team.

metabolic dietitian

protiens are ____% nitrogen

16

Over feeding of protein can also cause problems: - In "dry" patients -- Other consequences of excessive protein -

--Acidosis and azotemia --hypertonic dehydration (tube feeding syndrome) may result from obligate water losses ( high urea production) idiopathic hypercalciuria, osteoporosis, gout, and if >35% calories -- hyperammonemia, hyperaminoacidemia, hyper insulineamia, nausea...

MNT and Cancer 3 stages

--Preventative: Food components can inhibit or enhance carcinogenesis Achieve and maintain energy balance at a reasonable weight Plant based diet and limiting foods from animal sources, including red meats, processed meats, and poultry. Minimize toxic environments Practice chemoprevention --Acute treatment: Prevent or correct nutritional deficiencies Minimize weight loss (Metabolic stress) Maximize oral intake, use enteral and/or parenteral nutrition as needed. -- Survival: ~ to preventative

And children (1 -3 yrs.) __gm prot/kg/d

1.1

Pregnancy ___ gm/kg pre pg. wt. /d

1.1

Endurance athletes protien- g/kg/day

1.2 to 1.4

Nutritional management of Hypermetabolic stress Protein

1.5 - 2.0 g/kg/day to start; monitor response Nonprotein calorie/gram of nitrogen ratio for critically ill = 100:1 Giving exogenous aa's decreases negative N balance by supplying liver AA's for protein synthesis

Nutritional management of Hypermetabolic stress Fluid and Electrolytes

1.5 - 2.0 g/kg/day to start; monitor response Nonprotein calorie/gram of nitrogen ratio for critically ill = 100:1 Giving exogenous aa's decreases negative N balance by supplying liver aa's for protein synthesis

Weight typically increases an average of ___ to ___kg/ year ( 31/2 -7lbs) until ~ 9 - 10 years old.

1.6 3.3

Major burns result in severe trauma. Energy needs often increase to ____% above resting energy expenditure (REE). They are high risk for infection which increases both their protein and energy need The first 24 to 48 hours typically focused on fluid resuscitation. 2 to 4 ml/kg body weight per percentage of burn Note urine output is used to titrate the rate of IV fluid replacement.

100

Adolescence is one of the most challenging periods of human development nutritionally speaking _____ years of age It is a period of tremendous physiologic, psychologic and cognitive change

12 -21

spine trauma energy-- * with a hypocaloric and high protein is suggested in some patients -"permissive underfeeding" (____) in obese critically ill pts, achieves net protein anabolism and minimizes complications from overfeeding.

14kcal/kg

pounds to kilograms KNOW

2.2 lbs= 1kg

It is recommended that infants younger than 1 year --- __g fat per day.

30

Carbohydrates should supply __% to __% of caloric intake in infancy.

30 60

Clinical definition adds waist circumference* Stratifies disease risk for diabetes, hypertension and cardiovascular disease Directly related to waist circumference Men __ in. (___ cm) Women ___ in. (__ cm) * Asian-American waist cut offs are: for men > __in., women > __ in.

40/102 35/90 35/ 32

Macronutrient Distribution for an athlete Normal/fitness

45-55% carbohydrates (3-5 g/kg/d) 10-15% protein (0.8-1 g/kg/d) 25-35% from fat (0.5-1.5 g/kg/d) Comparing fuel sources Carbohydrates, preferred for skeletal muscle 4 kcal/g Lipids, highest E density, preferred by heart 9 kcal/g Protein reserved for other functions, training 4 kcal/g

Increases risk of heat exhaustion ___% loss of body weight due to sweating Heat Stroke ___% body weight lost Death Adults___% body weight lost Infants, __% body weight lost KNOW THESE NUMBERs

5 7-10 >10 2

% of heart attacks occur in people with normal serum cholesterol.

50

The ketogenic diet reduces seizure frequency by more than __% in half of the patients who try it and by more than __% in a third of patients. Three-quarters of children who respond do so within two weeks, though experts recommend a trial of at least three months before assuming it has been ineffective.

50 90

1oz protein~________ gram protein

7

__ essential amino acids ( EAA) __ Nonessential amino Acids

9 11

An RQ of ___________ may identify unusual metabolic or respiratory conditions

<0.7 or > 1.0

Hypocaloric Regimen for Obese Patients (BMI ___) Without renal or hepatic dysfunction ->___kcal/ideal body weight For patients with renal or hepatic dysfunction Mechanically ventilated - Ireton-Jones (1992) or Penn State ( 1998)

>30 22

(head injury where no change in structure noted, however a change in cellular metabolism is known)

A concussion

head injuries -It can be categorized into 3 types:

A concussion (no change in structure noted, however a change in cellular metabolism is known) Diffuse axonal injury - results from a shearing of axons of the brain inside the skull. Subdural hematomas - are often corrected by surgical intervention.

Rapid loss of LBM-- lean body mass, increased net nitrogen balance.

Acute phase proteins: --.

3 metabolic systems supply energy for our body:

Aerobic metabolism/oxidative phosphorylation ( O2 dependent) Creatine phosphate Anaerobic glycolysis

3 metabolic systems supply energy for our body:

Aerobic metabolism/oxidative phosphorylation ( O2 dependent) Creatine phosphate-- oxygen independant Anaerobic glycolysis -- oxygen independant --The use of one system or the other depends on the duration, intensity and type of --Physical activity.

Ergogenic Aids for Muscle Building, recovery antiinflammation

Amino Acids Branch chain amino acids Creatine B-hydroxyl-b - Methylbutyrate Hormones --- Prohormones/steroids

- results from a shearing of axons of the brain inside the skull.

Diffuse axonal injury

Among normal 'healthy' adults marginal deficiency is common...how can that be?

Due to busy and demanding lives marginal deficiencies may occur as a result of poor micronutrient intake, malabsorption or abnormal metabolism. Can be diagnosed with blood and tissue levels of a nutrient or concentrations of metabolites in urine. Patients often complain of fatigue, tiredness, and low energy levels...if no obvious underlying disease consider the possibility of marginal nutritional deficiencies. Our lifestyles are dependent on processed/convenience foods with low nutrient density Insufficient intakes due to chronic dieting Demanding periods of extensive exercise Emotional stress, burden of family, work demands Little time to shop, prepare and cook; rushed meals, unhealthy food choices, stress related behavior (smoking, excessive consumption of coffee!)

During _____ the body is faced with an obligate need to generate glucose to sustain cerebral energy metabolism (100 g of glucose day-1). This is achieved in the first 24 hours by mobilizing glycogen stores.

During starvation,

Include any training technique, mechanical device, nutrition practice, pharmacologic method or physiologic technique that can improve exercise performance capacity and training adaptations.

Ergogenic aids

The use of dietary supplements for this purpose is wide spread in all sports. It has been reported in track and field athletes - that they use supplements for the following reasons: 71% to in recovery from training 53% for health 46% to improve performance 40% to treat or prevent illness 29% to compensate for poor diet (Maughan et al, 2007)

Ergogenic aids pp.444 -446 Krause 14th ed. Table 23-5

Higher energy intakes associated with

Higher growth periods Normal adult 25-30 kcal/kg/d vs. Pregnancy (3rd trimester +300 kcal) /Lactation /Infancy High E needs for adult weight gain not to exceed 0.5-1 lb./wk., with fat < 33% of kcal protein intakes should be 1-1.5 g/kg of BW

- is a sensitive measure of chronic inflammation . NON-specific markers of inflammation

Hs-CRP - high sensitivity CRP

RDA (recommended daily amount) for energy and protein KNOW THIS TABLE

Infant and child 0 to 6 months 108 Kcal/kg 2.2g protein/kg 6 to 12 months 98 1.5 1-3 years 102 1.2 4-6 years 90 1.1 7-10 years 70 1.0 Adolescence Males 11-14 55 1.0 Males 15 -18 47 0.9 Females 11-14 45 1.0 Females 15-18 40 0.8

9 Kcal/gm C,H,O If not used immediately stored as TG in adipose tissue Since fat is essential in the diet, it's important to include good fats every day and to meet your daily need for essential omega-3 and omega-6 fats.

Lipids - (fat)

ketogenic diets as a lifestyle choice or for weight loss

Low-carbohydrate diets or low-carb diets are dietary programs that restrict carbohydrate consumption, often for the treatment of obesity or diabetes. Such diets are sometimes 'ketogenic' (i.e., they restrict carbohydrate intake sufficiently to cause ketosis). The induction phase of the Atkins diet is ketogenic. The term "low-carbohydrate diet" is generally applied to diets that restrict carbohydrates to less than 20% of caloric intake, but can also refer to diets that simply restrict or limit carbohydrates to less than recommended proportions (generally less than 45% of total energy coming from carbohydrates). No consensus definition exists of what precisely constitutes a low-carbohydrate diet. The American Academy of Family Physicians defines low-carbohydrate diets as diets that restrict carbohydrate intake to 20 to 60 grams per day, typically less than 20% of caloric intake.

Lower energy intakes associated with

Lowering BMI/weight loss, not to exceed 1-2 lbs./wk. Diabetes, heart disease , etc. Lower risk of breast cancers, etc. Longevity!!

Diets hi in ______ anti-inflammatory

MUFA, EFA MUFA - olive, peanut, canola, sesame oils, avocado ω- 3 increase collagen deposition, promote healing Recovery from concussions? Concerns - fish Hg contamination; ALA in F&V but slower conversion to DHA, EPA; walnuts, salmon, tuna, spinach, tofu, shrimp)

Physical activity and hyperlipidemia and Atherosclerosis Medical management Lifestyle change: Nutrition management

Medical management Lifestyle change: Exercise/ Stress management Medications/ TG's / HTN/ Glucose control/ surgical Nutrition management DASH dietary pattern/ Mediterranean diet pattern/ Weight reduction if needed/ Increase fiber to 25 -30g/day or more Add omega 3 fats from food/ Add fruits and vegetables/ CoQ10 for those on Statin drugs

Clinical definition adds waist circumference* Stratifies disease risk for diabetes, hypertension and cardiovascular disease Directly related to waist circumference Men = Women = * Asian-American waist cut offs are: for men =

Men 40 in. (102 cm) Women 35 in. (90 cm) * Asian-American waist cut offs are: for men > 35in., women > 32 in.

Nutrient needs of infants reflect rates of growth, energy expended in activity, basal metabolic needs, and the interaction of nutrients consumed. By monitoring an infants growth rate ( Wt./age, Ht./age, wt./ht. and HC) you can adequately assesses their energy intake.

Metabolic needs change through out the lifespan

Calculation of daily water requirements Method 2 16 to 30 years, active 20 to 55 years 56 to 75 years >75 years

Method 2 16 to 30 years, active 40 ml/kg 20 to 55 years 35 ml/kg 56 to 75 years 30 ml/kg >75 years 25 m/kg

Medical nutrition therapy

Minimize metabolic stress response. Control temperature, pain and anxiety, maintaining fluid and electrolyte balance. Meet nutritional needs Adequate calories to prevent >105 loss of usual body weight. Protein adequate for positive nitrogen balance. Provide vitamin and mineral supplements as needed. Prevent Curling stress ulcer - by providing antacids or continuous enteral feedings

What are the consequences of inadequate intake of b vitamins?

Mitochondrial functions are compromised by insufficient dietary intake of B vitamins and/or increased needs. physical activity depletes or uses up our micronutrients which must be replaced for good function (like our water soluble vitamins...) so in the field of sports medicine and with a focus on athletes supplementation is a common strategy..... But, we must first maximize one's diet before adding supplements.

serve transport functions exert the colloid osmotic pressure needed to maintain fluid in vascular space.

Plasma proteins

is the ratio of vCO2 and vO2 and is a function of the mix of substrates being utilized for metabolism.

Respiratory quotient (RQ)

They have many clinical manifestations, depending on the level of injury. Complete transection -> complete loss of function below the level of the lesion. The body's response to traumatic brain injury (TBI)/spinal injury - results in the production of cytokines and inflammation.

Spine trauma and spinal cord injury

______ phase- occurs immediately following injury (hypovolemia, decreased basal metabolic rate, reduced cardiac output, Hypothermia, lactic acidosis, shock, and tissue hypoxia) and it lasts for approximately 24-48 hours

The Ebb phase

Metabolic stress: Critical illness, Sepsis, Trauma, burns and Surgery Typically has 2 phases:

The Ebb phase - occurs immediately following injury (hypovolemia, decreased basal metabolic rate, reduced cardiac output, Hypothermia, lactic acidosis, shock, and tissue hypoxia) and it lasts for approximately 24-48 hours The Flow phase - follows fluid resuscitation and restoration of Oxygen transport. This phase involves the mobilization of body energy stores for recovery and repair, and the subsequent replacement of lost or damaged tissue. The flow phase may be subdivided into an initial catabolic phase, lasting approximately 3-10 days, followed by an anabolic phase, which may last for weeks if extensive recovery and repair are required following serious injury.

_______ - follows fluid resuscitation and restoration of Oxygen transport. This phase involves the mobilization of body energy stores for recovery and repair, and the subsequent replacement of lost or damaged tissue. ________ may be subdivided into an initial catabolic phase, lasting approximately 3-10 days, followed by an ______, which may last for weeks if extensive recovery and repair are required following serious injury.

The Flow phase The flow phase anabolic phase-- must monitor electrolytes

Heart disease diets

The Mediterranean diet- features Complex carbohydrates, 30 -35% calories from fat/low saturated fat < 10%, high in omega-e, and high in fiber ( 27-37g/d). DASH Diet (The Dietary Approaches to Stop Hypertension) Plant based diet, low in animal protein and sugar. Vegan diet - includes no dietary sources from animal origins. - can reverse atherosclerotic cardiovascular disease.

Estimating Energy Needs/predictive equations

The Original Harris-Benedict Equation (1919) ->not in critically ill patients. Metropolitan Life Insurance Weight Standards (1943) Hamwi method (1964) The Revised Harris-Benedict Equation (1984) The Mifflin-St Jeor Equation, 5% more accurate (1990)-not for critically ill patients use the Penn State equation for patients <60 yr.. For critically ill patient if you do not have access to indirect calorimetry

carbohydrate and lipid metabolism in the liver (ex. ↑ glycolysis) ____ would influence fuel metabolism .

Thyroid hormone effects hypothyroidism

Adipocytes are biologically _______ type of organs that produce ________

active -not just fat storage, but endocrine organs.

. Factors affecting the protein needs of athletes include;

age, gender, mass, fitness level and phase of training.

The digestibility of a particular protein ( food) - looked at by the WHO and FDA - you will hear it referred to as the ____. (After correcting for digestibility proteins that provide AA at recommended levels or more are given a score of 1)

amino acid score

Recognize the importance of protein in appropriate amounts

amino acids can be converted to glucose by gluconeogenesis in the liver all aminoa acids can be used for ATP production. When needed, protein from muscles broken down and amino acids are released into the blood when basic requirements for aminoa acids have been met, excess amino acids are converted to fatty acids

the metabolic stress response may be further exacerbated by ________________. Thus, any attempt to limit or control these other factors is beneficial to the patient. Avoidable factors:

anaesthesia, dehydration, starvation (including preoperative fasting), sepsis, acute medical illness or even severe psychological stress Hemorrhaging/ Hypothermia/ Tissue edema/ Under perfusion of tissue/ Starvation/ Immobility

Injury results in profound metabolic alterations, beginning at the time of the insult and persists until wound healing and recovery are complete. The metabolic response is complex and involves most of the body's metabolic pathways. Accelerated _____ of _____ occurs --> ______ nitrogen balance and muscle _____.

catabolism of lean body mass (LBM) negative wasting

After releasing the lipid luminal bile salts are recycled in a process called ____ The pool of bile acids may recirculate 3 to 15 times per day depending on how much food is ingested. In the enterocyte, FA's and monoglycerides are reassembled into new triglycerides. Increased motility, intestinal mucosal changes, pancreatic insufficiency, or the absence of bile decreases fat absorption. Steatorrhea = fat in feces

enterohpepatic circulation.

High carbohydrate diet was used to guide athletes to enhance maximized glycogen stores for the best endurance performance. Traditionally, the 7 day carbohydrate-loading approach combined muscle-specific depletion training with a low-carb diet for 4 days followed by 3 days of high carb and little to know training. This packs up to 5 g glycogen per 100g muscle ( usual is 1.7g/100gmuscle). Glycogen is water heavy - 2.7g water for each g of glycogen- which can hinder performance. Now there is a modified approach of gradual exercise tapering along with modified increases of carbohydrates. Types of carbohydrate that are best are still debated Food timing Pre-training --(4 hours before a meal only 25% calories from fat, 200 -350 g carb this is about 4g.kg; and include a lean protein source) Training fuel during exercise -for exercise lasting longer than 1 hour, 25 to 30 g q 30 minutes Post workout and recovery fuel -only 5% of muscle glycogen used in exercise is resynthesized each hour after exercise. High glycemic choices are best at this stage. Improved with 5 to 9 gm protein with each 100g carbs.

glycogen loading

gold standard for energy estimate intake needs

indirect calorimetry

Waist fat is important because it contributes to

inflammatory response, which can contribute to illness

the period immediately after feeding where nutrients are absorbed into the blood

postprandial period

High ____ diets can also contribute to dehydration.

protein

MOST ____ digestion takes place in the upper portion of the small intestine, but also CONTINUES throughout the GIT*.

protein Contact between chime and the intestinal mucosa ------release of enterokinase --- transforms inactive pancreatic trypsinogen into active trypsin.

Gout -disorder of________ hyperuricemia Probably from ↑ xanthine dehydrogenase activity catalyzes production of uric acid from hypoxanthine (purine metabolite) Uric acid (sodium urates) deposited in and around joints Treated with drugs, diet Drugs: ↓ enzyme activity Diet: ↓ purine intake (meat, seafood, alcohol) Diet: low-fat dairy, ascorbic acid, wine may be protective due to alkaline ash effect

purine metabolism

9 AA are essential- they MUST be obtained, in sufficient amounts, from diet for our health.

pvt tim hall phenylalnine valine tryptophan threonine

The energy needs of healthy children are determined by rates of growth, energy expended in activity, basal metabolic needs. NOTE - Kids need ______ for good eating! (See, say and do!) Family meals are critical to development of normal healthy meal patterns.

role models

Higher micronutrient intakes needed for

smokers, alcoholics, chronic conditions, alcoholics, excessive exercise, etc.

Health care providers often overlook PEM WHY????

stereotypes difficult to see aceities in obese patients no hands on aspects of care

Medical managmenet of Hypermetabolic stress

treat cause of hyper metabolism physical therapy exercise Detect and correct preexisting malnutrition Prevent progressive protein-calorie malnutrition Manage fluid and electrolytes to optimized patient's metabolic state Pediatric patients are more difficult to treat because their needs for nutrients and calories Must supply for healing and for growth!!!! Work with a pediatric RD.

starvation= _____ (time) glucose is obtained by hepatic gluconeogenesis from amino acids, glycerol and lactate. Additionally, lipid is mobilized and metabolized to supply other tissues which is largely dependent on a fall in circulating insulin levels. If the fast goes on, the liver converts free fatty acids into _____ which can be used for cerebral metabolism.

~ day 2, ketones

Circumvent the missing or inactive enzyme by:

-Restricting the amount of substrate available -Supplementing the amount of product -Supplementing the enzymatic cofactor -Combining any or all of these approaches

RDA = _ g protein/kg body weight, healthy adults 95% of protein absorbed Plant protein more difficult (Ex. soybeans trypsinase) 80% of body need met by 'recycling'

0.8

14 to 18 about ___ gm/kg/day

0.85

4 to 13 yrs. - __ gm/kg/day

0.95

Strength training protien - g/kg/day

1.2 to 1.7

Resistant training protien - g/kg/d

1.2 to 2

Lactation __gm/kg/d

1.3

Infants need up to __ gm protein/kg/d

1.5

Protein - ______ to _____ % of your total calories choose lean protein ( either plant based animal based)

10 to 35

Acceptable Macronutrient Distribution Ranges ____% of energy (most liberal) Assumes kcal intake is sufficient DGAs

10-35 Fat-free or low-fat milk 1-2 c 2-7 oz. lean meat Legumes - 2-3 cups

Typical American diet provides > ----g prot./day

100

The loss of LBM, relative to normal, corresponds with major complications. A loss of more than ___% of total will impair wound healing, A loss of ___% or more leads to the development of spontaneous wounds such as pressure ulcers, and wound dehiscence (late stage) Death occurs with ___% LBM loss, usually from pneumonia

15 30 40

Since the ____'s there has been mandatory New Born Screening (NBS) in the USA with the Guthrie bacterial inhibition assay in which dried blood spots were assayed. With this we were able to identify hemoglobinopathies, endocrine disorders, metabolic disorders and some infectious disorders.

1960

____'s tandem mass spectrometry started being used in NBS ->this multiple disorders to be identified with the blood spots. This program screens for congenital hypothyroidism, phenylketonuria, congenital adrenal hyperplasia, galactocemia, sickle cell disease, and maple syrup urine disease.

1990

Fat - ______ to _____ % of total calories Avoid trans fats!, minimize saturated fats for disease prevention,

20 - 35

Protein requirements are increased in certain conditions- _______% Surgery Burns (High quality protein -- intakes ___% of energy intake) due to losses in urine, wounds,

20-25

Protein is our second largest energy store... __net Kcal per gram

4 Know how to calculate the protein content of a meal- 1oz protein~7gram protein

Carbohydrates - ____ to ____ % of total daily calories Focus should be on complex carbohydrates.

45 to 65

severe wasting weight for height standard deviation

<-3 SD

severe wasting MUAC-- Mid upper arm circumfrence

<115mm

Cannot synthesize lipoproteins containing apolipoprotein B Fat malabsorption due to reduced chylomicron formation

Abetaliproteinemia

(cho) C, H20 4 Kcal/gm and are categorized as complex or simple Stored as glycogen in muscle and, liver cells. Has osmotic affect in the intestinal lumen Complex _______ like vegetables and whole grains, contain fiber which has a beneficial impact both on satiety and blood sugar.

Carbohydrates carbohydrates

______is a major factor affecting protein quality - and is affected by many factors including food processing. (True for both animal and plant protein) cooking makes protein easier/harder to digest

Digestibility easier

There is an absence or reduced activity of a specific enzyme or cofactor Most are autosomal recessive: both parents carry trait to pass it on. Often early treatment, carefully continued throughout life, allows normal physical and cognitive development Sometimes careful treatment does not prevent cognitive and physical damage

Genetic Metabolic Disorders

critical patient and/or the chronic patient suffer with frequent inflammation and infection you will need to -pause and think. What is their protein need, calorie need and state of catabolism? At this point consider a referral to a critical care RD.

Illness causes protein catabolism and affects interpretation of serum protein values! There is stress -related protein energy malnutrition

Acute illness or trauma causes inflammatory stress. Hormones and cell -mediated responses trigger the break down of lean body mass Evaluation of nutrition status of such patients is difficult because _____ of the standard laboratory tests will truly reflect changes in protein status during the onset of the illness or during refeeding.

NONE

Basic unit is amino acid (AA), determines quality 5 kcal/g, -1 kcal/g for deamination - thus, 4 kcal/g

Protein

digestion begins in the stomach, where some of the protein are split into proteases, peptones, and large polypeptides.

Protein

located on the brush boarder also act on polypeptides, breaking them down into amino acids (AA), dipeptides, and tripeptides.

Proteolytic peptidases

Role of the RD in Genetic metabolic disorders

Your pediatric RD needs special training in this area. Provides MNT for the specific disorder Family centered counseling approach - it is a lifelong treatment

Proteins differ from carbohydrates and lipids in that they contain

nitrogen (they are 16% N).

aceities is a ______ deficinecy symptom with _____ deficiency, wounds take longer to heal marasmus

protein protein protein energy malnutrition

Basic unit is amino acid (AA), determines quality

protien

The activation of the _________, will block the body's adaptive responses - which would allow the protein to be used for fuel.

stress response

major functions of proteins in the body

structure-- collagen catalyst-- enzymes movement-- muscle actin myosin transport-- membrane bound transport proteins albumin communication-- hormones-- insulin cell signalling protection-- skin proteins fibrinogens antibodies regulation of fluid balance-- albumin regulation of pH-- charged amino acids hemoglobin