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/g

Total energy requirement can be estimated by BMI

Energy 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 NEEDS

PHYSIOLOGICAL FACTORS

Age gender Growth Pregnancy & lactation Increased physical activity

DIETARY COMPOSITION

Affects 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- minerals DISEASE specific dietery deficiency diseases megaloblastic anemia- vit B12 & FA Rickets- vit D scurvy- vit C Ber-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(240-450g/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

 Proteinenergy 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. Proteinenergy 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 proteinenergy

malnutrition occurs primarily in association with hypermetabolic acute illnesses such as trauma, burns, and sepsis. Marasmus-like secondary proteinenergy malnutrition typically results from chronic diseases such as chronic obstructive pulmonary disease (COPD), congestive heart failure, cancer, or AIDS.

Pathophysiology
Proteinenergy malnutrition affects every

organ system. The most obvious results are loss of body weight, adipose stores, and skeletal muscle mass. Weight losses of 510% are usually tolerated without loss of physiologic function; losses of 3540% 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 patients 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 18.524.9. Overweight is defined as BMI = 2529.9. Class I obesity is 3034.9, class II obesity is 3539.9, 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 selfinduced vomiting, diuretic or cathartic use, or strict dieting or vigorous exercise.

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