Nutrition in Med I
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Transcript of Nutrition in Med I
NUTRITION IN MEDICINE
DR. SHRADDHA THOURANI
Nutrients are the substances that are not synthesized by the human body and are therefore to be supplied by the diet. Macronutrients and micronutrients Illness and injury alter the nutritional
requirements Increase need with growth, pregnancy,
lactation, exercise. Nutrient required for good health are Energy providing foods – carbohydrates,
fats and proteins Vitamins Minerals Water
Human requirements for organic nutrients include 9 essential amino acids, several fatty acids, glucose, 4 fat-soluble vitamins, 10 water-soluble vitamins, dietary fiber, and choline.
Several inorganic substances, including 4 minerals, 7 trace minerals, 3 electrolytes, and the ultra trace elements, must also be supplied by diet
ENERGY
LAW OF THERMODYNAMICS Energy intake= energy expenditure Average energy intake in males is 2600kcal/d
and 1900kcal/d in females BMR is the obligatory energy reqd to maintain
the metabolic functions in tissues Extra metabolic energy is consumed during
growth, pregnancy, lactation and when febrile Metabolic energy is also reqd for thermal
regulation
Energy intake is determined by the ‘macronutrient’ content of food.
Energy provided by each is: Carbohydrates – 16kJ/g Fat 37kJ/g Proteins 17kJ/gTotal energy requirement can be
estimated by BMIEnergy given per kg of body weight is
inversely related to BMI
DAILY ADULT ENERGY REQ
FEMALES MALES
AT REST 1600 kcal 2000 kcal
LIGHT WORK 2000 kcal 2700 kcal
HEAVY WORK 2250 kcal 3500 kcal
ENERGY YIELDING NUTRIENTS
CARBOHYDRATES, FATS AND PROTEINS Carbohydrates (starches and sugar) supply the
major part of energy 45-55% of total calories. Sugars – fruits, milk and vegetables. Total
recommended intake of sugars is between 0 -15% of total energy intake
Starches – cereals, root vegetables and legumes. They are the nutrients which provide the largest proportion of calories reqd.
Dietary fibers – non-starch polysaccharides Glycemic index
FATS Because of the high calorie value
provide more energy and exessive consumption may be the insidious cause of obesity
Fats can be classified as saturated, and unsaturated (monounsaturated and polyunsaturated)
PUFA – Linoleic acid and alpha linoleic aid are “essential” fatty acids
Fish oils are rich in PUFA –prevent coronary heart disease
Trans fatty acids (TFA) and saturated fats should be limited to <10%
PROTEINS
Proteins form the structural component of the body cells.
Proteins are made up of 20 different amino acids out of which 9 are essential amino acids that cannot be synthesized within the body and has to be obtained from dietary sources
Nutritive value or biological value Proteins of animal origin like eggs , milk and
meat have higher biological value than proteins of vegetable origin
Recommended proteins is 10% of total calories or about 65g per day for an average adult
CLINICALLY IMP VITAMINS
Fat soluble – vitamin A,D,E,K Water soluble vitamins – B1,B2,B3,B6 Folate – B12 Biotin Ascorbic acid
MINERALS Calcium, phosphorus , magnesium, iron,
zinc, iodine , selenium, copper , fluoride, potassium and sodium
FACTORS ALTERING NUTRIENT NEEDSPHYSIOLOGICAL FACTORS
Age gender Growth Pregnancy & lactation Increased physical activity DIETARY COMPOSITIONAffects the biologic availability of nutrients.ex.Fe & Ca , Fe + vit C
ROUTE OF ADMINISTRATION Oral- CHO, fats, amino acids, Na, K, Cl
have good intestinal absorption Parenteral- mineralsDISEASEspecific dietery deficiency diseasesmegaloblastic anemia- vit B12 & FARickets- vit Dscurvy- vit CBer-Beri/pellegra
NUTRITIONAL STATUS ASSESSMENT
ASSESSMENT OF NUTRITIONAL DEFICIENCIES
(I) NUTRITIONAL HISTORY Poor intake (anorexia, food avoidance, NPO
status) Nutrient losses – malabsorbtion ,abscesses,
wounds Hypermetabolic states- fever,sepsis,trauma,
burns Steroids, antimetabolites(methotrexate),
immunosuppressants, anticancer drugs Advanced age, poverty, isolation Increased requirements of nutrients
(II) PHYSICAL FINDINGS HAIR AND NAILS
Coiled, sparse, easily pluckable hair Depigmentation of hair Transverse ridging of nails
SKIN Crackling, dry, hyperkeratotic skin Scaling Poor wound healing with ulcers
ORAL Angular stomatitis, cheilosis Dry crackling lips Glossitis Bleeding gums
BONES AND JOINTS Beading of ribs, epiphyseal swelling, bowlegs
NEUROLOGIC Drowsiness, lethargy, disorientation Dementia, headache Peripheral neuropathy
OTHERS Edema Hepatomegaly Heart failure
(III) ANTHROPOMETRY
Anthropometric measurements provide information on the body muscle mass and fat reserves.
Weight and height to know the BMI Triceps skinfold (TSF) Mid arm muscle circumference (MAMC)
BMI – BODY MASS INDEX= WEIGHT(kg)HEIGHT(m)2
Classification of weight status
BMI CLASS
< 18.5 UNDERWEIGHT
18.5-24.9 HEALTHY
25-29.9 OVERWEIGHT
>30 OBESE
(IV) Laboratory tests
Serum albumin or total proteins(3.5-5.5g/dl)
Serum iron binding capacity(240-450µg/dl)
Serum B12 levels(279-996pg/ml) Prothrombin time(21-15.5 sec) Serum Creatinine (0.6-1.6mg/dl) BUN (8-23mg/dl)
SUMMARY
NUTRITIONAL ASSESSMENT Proper and complete history Physical signs Anthropometry Laboratory investigations
PEM IN ADULTS
Protein–energy malnutrition occurs as a result of a relative or absolute deficiency of energy and protein.
It may be primary, due to inadequate food intake,
or secondary, as a result of other illness. Protein–energy malnutrition has been described
as two distinct syndromes. Kwashiorkor, caused by a deficiency of protein
in the presence of adequate energy, is typically seen in weaning infants.(protien poor diet)
Marasmus, caused by combined protein and energy deficiency, is most commonly seen where adequate quantities of food are not available.(end result of long term dietery deficiancy)
Kwashiorkor like secondary protein–energy malnutrition occurs primarily in association with hypermetabolic acute illnesses such as trauma, burns, and sepsis.
Marasmus-like secondary protein–energy malnutrition typically results from chronic diseases such as chronic obstructive pulmonary disease (COPD), congestive heart failure, cancer, or AIDS.
Pathophysiology
Protein–energy malnutrition affects every organ system.
The most obvious results are loss of body weight, adipose stores, and skeletal muscle mass.
Weight losses of 5–10% are usually tolerated without loss of physiologic function; losses of 35–40% of body weight usually result in death.
Loss of protein from skeletal muscle and internal organs
Protein mass is lost from the liver, gastrointestinal tract, kidneys, and heart.
Hepatic synthesis of serum proteins decreases.
Cardiac output and contractility are decreased
Respiratory function is affected due to atrophy of the muscles of respiration.
The gastrointestinal tract is affected by mucosal atrophy and loss of villi of small intestine, resulting in malabsorption.
mild pancreatic insufficiency also occur. Changes in immunologic function are
seen.
CLINICAL FEATURES Loss of weight Loss of subcutaneous fat Muscle wasting Thirst, weakness, feeling cold Lax, pale, dry skin Hair thinning or hair loss Generalized oedema Distended abdomen Diminished tendon jerks Apathy, depression Increased susceptibility to infections
Progressive wasting that begins with weight loss and proceeds to more severe cachexia
body fat stores disappear and muscle mass decreases, most noticeably in the temporalis and interosseous muscles.
Laboratory studies may be unremarkable—serum albumin,
The serum protein level, however, typically declines and the serum albumin is often < 2.8 g/dL (< 28 g/L).
Dependent edema, ascites, or anasarca may develop.
Infections asso with PEM
Gastroenteritis Respiratory infections –
bronchopneumonia Tuberculosis Streptococcal and staphylococcal
skin infections Viral infections like herpes Helminthic infestations
Treatment
Initial efforts should be directed at correcting fluid and electrolyte abnormalities and infections.
The second phase of treatment is directed at repletion of protein, energy, and micronutrients.
Treatment is started with modest quantities of protein and calories calculated according to the patient’s actual body weight.
vitamins and minerals by enteral or parenteral route
Enteral refers to feeding via a tube placed into the gut to deliver liquid formulas containing all essential nutrients.
For short-term use, enteral tubes can be placed via the nose into the stomach, duodenum, or jejunum.
For long-term use, these sites can be accessed through the abdominal wall using endoscopic, radiologic, or surgical procedures
Parenteral refers to the infusion of complete nutrient solutions into the bloodstream via a peripheral vein or, more commonly, by central venous access to meet nutritional needs
Percutaneous placement of a central venous catheter into the subclavian or internal jugular vein with advancement into the superior vena cava can be accomplished at the bedside by trained personnel using sterile techniques
OBESITY
OBESITY
Obesity is one of the most common disorders in medical practice and among the most frustrating
Obesity is defined as an excess of adipose tissue.
Physical examination is usually sufficient to detect excess body fat.
More quantitative evaluation is performed by calculating BMI.
The BMI is calculated by dividing measured body weight in kilograms by the height in meters squared.
classification
The National Institutes of Health (NIH) define a normal BMI as 18.5–24.9.
Overweight is defined as BMI = 25–29.9.
Class I obesity is 30–34.9, class II obesity is 35–39.9, and class III (extreme) obesity is BMI
> 40.
Obesity is associated with significant increases in both morbidity and mortality
Obese patients have a greater risk of diabetes mellitus, stroke, coronary artery disease, and early death
The most important and common of these are hypertension, type 2 diabetes mellitus, hyperlipidemia, coronary artery disease, degenerative joint disease, and psychosocial disability.
Certain cancers (colon, ovary, and breast),
thromboembolic disorders, digestive tract diseases (gallbladder
disease, gastroesophageal reflux disease), and
skin disorders are also more prevalent in the obese
Obese patients also have a greater risk of pulmonary functional impairment including sleep apnea.
endocrine abnormalities, proteinuria, and increased hemoglobin concentration.
Patients with obesity have increased rates of major depression and binge eating disorder
TREATMENT
Dietery restrictions and modifications Exercise Medications – Orlistat which reduces
fat absorbtion. Bariatric surgery is an increasingly
prevalent treatment option for patients with severe obesity. Roux-en-Y gastric bypass (RYGB), done laparoscopically
Gastric banding (GB) surgeries
EATING DISORDERS
Anorexia Nervosa typically begins in the years between adolescence and young adulthood. Ninety percent of patients are females.
The diagnosis is based on weight loss leading to body weight 15% below expected.
fear of weight gain or of loss of control over food intake and, in females, the absence of at least three consecutive menstrual cycles.
Bulimia Nervosa is the episodic uncontrolled ingestion of large quantities of food followed by recurrent inappropriate compensatory behavior to prevent weight gain such as self-induced vomiting, diuretic or cathartic use, or strict dieting or vigorous exercise.
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