Energy Metabolism and Normal Nutritional Requirements FERNANDO L.

LOPEZ, MD, FPCS Professor of Surgery UST Department of Surgery Compiled and edited by Arvin 09-01-08 OBJECTIVES 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 NUTRIENTS Protein 4 kcal / g Carbohydrates o enteral 4 kcal / g o parenteral 3.4 kcal / g Lipids 9 kcal / g Water Vitamins o Water soluble o Fat soluble Minerals o Electrolytes o Trace elements and ultra trace minerals

Chemical Structure of an Amino Acid

NITROGEN BALANCE

NB = IN (UN + RNL)
NB: Nitrogen Balance IN: Ingested Nitrogen UN: 24-Hour Urine Nitrogen RNL: Remaining Nitrogen Loss (3.1 g/d) Respiratory Quotient (RQ)

RQ: Respiratory Quotient VCO2: CO2 Produced VO2: Oxygen Consumed RQ Glucose oxidation 1 glucose + 6 O2 = 6 CO2 + 6 H20 Fat oxidation 1 palmitate + 23 O2 = 16 CO2 + 16 H2O Protein oxidation 1 amino acid + 5.1 O2 = 4.1 O2 + 2.8 H2O Lipogenesis Nutrient Utilization Regulation Nutrient availability Hormonal environment Inflammatory state 6/6 = 1.0 16/23 = 0.7 4.1/5.1 = 0.8 > 1.0 8.0

Amino Acids NON-ESSENTIAL CONDITIONALLY Isoleucine Alanine ESSENTIAL Phenylalanine Glutamine Methionine Arginine Histidine Tryptophan ESSENTIAL Tyrosine Leucine Aspartic Acid Lysine Glutamic Acid Valine Cysteine Threonine Glycine Serine Proline

NUTRITIONAL REQUIREMENTS Objectives 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 Metabolic Reaction to Starvation Hormone Source Norepinephrine Norepinephrine Epinephrine Thyroid Hormone T4 Sympathetic Nervous System Adrenal Gland Adrenal Gland Thyroid Gland (changes to T3 peripherally)

Change in Secretion

Energy Expenditure in Starvation

Energy Substrate Utilization Fasting state: o Depends on nutrient availability In stress: o Depends on hormonal environment and inflammatory response

Body Composition Weight (kg) 70 Total Water (L) Intracellular Extracellular Total Solids (kg) 42 28 14 28

60 31 19 12 28.8

Weight (kg) Fat (kg) BCM Protein (kg) Minerals (kg)

70 12.5

60 Metabolic Response to Trauma 17

12.5 3

9 3

MALNUTRITION In malnutrition, energy expenditure must be calculated based on actual body weight. OBESITY In obesity, energy expenditure must be calculated on ideal weight. Calculating Basal Energy Expenditure Harris-Benedict Equation o Variables gender, weight (kg), height (cm), age (years) Men: 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 Calorie Calculation Rule of Thumb Calorie requirement = 25 to 30 kcal/kg/day METABOLIC RESPONSE TO STARVATION AND TRAUMA: METABOLIC RESPONSE TO TRAUMA: EBB PHASE Characterized by hypovolemic shock Priority is to maintain life/homeostasis o Cardiac output o Oxygen consumption o Blood pressure o Tissue perfusion o Body temperature o Metabolic rate METABOLIC RESPONSE TO TRAUMA: FLOW PHASE Catecholamines Glucocorticoids Glucagon Release of cytokines, lipid mediators Acute phase protein production Metabolic Response to Trauma

Metabolic Response to Overfeeding Hyperglycemia Hypertriglyceridemia Hypercapnia Fatty liver Hypophosphatemia, hypomagnesemia, hypokalemia Macronutrients during Stress CARBOHYDRATE 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 FAT Provide 20%-35% of total calories Maximum recommendation for intravenous lipid infusion: 1.0 -1.5 g/kg/day Monitor triglyceride level to ensure adequate lipid clearance PROTEIN Requirements range from 1.2-2.0 g/kg/day during stress Comprise 20%-30% of total calories during stress Determining Protein Requirements for Hospitalized Patients

Severity of Trauma: Effects on Nitrogen Losses and Metabolic Rate

Metabolic Response to Starvation and Trauma Starvation Trauma or Disease Metabolic rate Body fuels conserved wasted Body protein conserved wasted Urinary nitrogen Weight loss slow rapid The body adapts to starvation, but not in the presence of critical injury or disease. Calorie Distribution Shift in Catabolism Normal Catabolic Fat 25% 30% Protein 15% 25% Carbohydrate 60% 45% Determining Calorie Requirements Indirect calorimetry Harris-Benedict x stress factor x activity factor 25-30 kcal/kg body weight/day Metabolic Response to Starvation and Trauma: Nutritional Requirements Injury Stress Factor Minor surgery 1.00 1.10 Long bone fracture 1.15 1.30 Cancer 1.10 1.30 Peritonitis/sepsis 1 10 1 30 Severe infection/multiple trauma 1.20 1.40 Multi-organ failure syndrome Burns Activity Confined to bed Out of bed 1.20 1.40 1.20 2.00 Activity Factor 1.2 1.3

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 Role of Arginine in Metabolic Stress 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 Key Vitamins and Minerals Vitamin A Vitamin C B Vitamins Pyridoxine Zinc Vitamin E Folic Acid, Iron, B12

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

Nutritional Assessment Medical history Physical examination Biochemical markers Anthropometric measures 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 Mini Nutritional Assessment (MNA)6 Nutritional Risk Index (NRI)7 Subjective Global Assessment

Evaluation of Weight Change Time Significant Weight Loss 1 week 1% to 2% 1 month 5% 3 months 7.5% 6 months 10%

Severe Weight Loss > 2% >5% 7.5% 10%

* Values charted are for percent weight change: Percent weight change = (usual weight - actual weight) x 100 usual weight Nutritional Requirements Indirect Calorimetry Harris-Benedict formula with Long modification

Short Method Underweight: ABW x 25 - 30 kcal/kg Overweight: IBW x 25 -30 kcal/kg Protein Requirements Non-Stressed - 0.8 gm/kg/day Mildly Stressed - 1-1.2 gm/kg/day Severely Stressed - 1.5-2 gm/kg/day Protein should comprise approximately20% of the total calories during stress Non-Protein Calories Carbohydrate Fats NPC combinations o acute stress: 70% carbo 30% fat o usual: 60% carbo 40% fat o infections: 50% carbo 50% fat o pulmonary: 40% carbo 60% fat Vitamin and Mineral Requirements Micronutrient, trace element, vitamin and mineral requirements of metabolically stressed patients are elevated above normal Give vitamin and mineral requirements daily Nutritional Interventions Nutritional counseling Oral supplementation Enteral tube-feeding Parenteral feeding Enteral or Parenteral: Selecting the Route of Delivery If the gut works, use it.

NUTRITIONAL ASSESSMENT BIOCHEMICAL MARKERS Serum albumin Serum transferring Serum prealbumin Total lymphocyte count Serum cholesterol Nitrogen balance ANTHROPOMETRIC MEASURES Height, Weight, TSF, MAC BMI NOMOGRAM Underweight <18.5 Normal 18.5 - 25 Overweight 25 - 30 Obese >30 NUTRITIONAL RISK ASSESMENT FORM

The rationale for early EN Use of the gut stimulates GALT & MALT resulting in enhanced immune response Early feeding can trigger gut immunity and thereby improve outcomes Delay or failure may promote a proinflammatory state with disease severity & morbidity Enteral Formulas: Categories Polymeric formulas o Commercial o Blenderized Oligomeric formulas Disease-specific formulas Modular formulas (concentrated protein and carbohydrate preparations) Polymeric Formulas Contain intact macronutrients and require digestion: o Intact proteins o Polysaccharides o Disaccharides o Polyunsaturated fatty acids (PUFA) o Medium-chain triglycerides (MCT) o Vitamins and minerals Oligomeric Formulas Hydrolyzed macronutrients facilitate digestion and absorption Components Glucose polymers Amino acids Polyunsaturated fatty acids Glutamine Medium-chain triglycerides Arginine Vitamins and minerals Peptides Monosaccharides Disaccharides Also called elemental, semi-elemental, All in One Parenteral Formulas Optimal utilisation of calories Minimizes metabolic complications o reduced volume load o reduced CO2 production o avoidance of hyperglycaemia o less fat synthesis Permits peripheral administration Access for Parenteral Nutrition Central PN Percutaneous Subclavian / Jugular Femoral PIC line Cutdown Basilic vein External jugular Aseptic technique required at all times

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 ! ROUTE OF DELIVERY Early & preferential use of EN, combined with PN whenever necessary MONITORING IMPLEMENTATION Pre-op: Monitor actual intake as an index of success Post-op: Monitor clinical parameters 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 DOCUMENTATION

-arvin 09-01-08

Peripheral PN Any peripheral vein Aseptic technique required at all times Best removed after 48 72 hrs

Take home message (1) ROUTINE SCREENING Assessment of risk for nutrition related complications High index of suspicion Consider nature of illness and over-all condition of patient in the context of a second insult ACCURATE ASSESSMENT