1. Nutrition and Dietetics in the Normal Patient

2. Study Aims Definition Nutritional assessement
Malnutrition
Actual body weight
Ideal body weight
Predicted body weight
Nutritional assessement
Calculation of nutritional needs
Complications of overfeeding

3. Introduction Malnutrition common Predisposition to
Defined as 10% of USUAL body weight
Predisposition to
Delayed healing
Post-operative Infection
Added Morbidity and Mortality
Recognition thus important
Preventable disease
Treatable disease

4. Introduction (cont . . .) Usual / actual body weight Ideal body weight
As measured by scale
Ideal body weight
Male H2 * 20
Female H2 * 25
Predicted body weight
Male (Height in cm – 152.4)
Female (Height in cm – 152.4)

5. Nutritional Assessment
History and examination
Anthropological markers
Biochemical markers
Calculations of energy and protein requirements

6. Nutritional Assessment History
Pre- morbid conditions
Estimates the risk of malnutrition
Hepatic and renal failure
IBD
Cancer and HIV/AIDS
Burns and head injuries
Conditions that limit intake or increase output
History of recent weight loss
Dietary Hx
Intake concerning calory (energy), protein, vitamin and trace elements

7. Nutritional Assessment Physical Examination
Caloric intake
Subcutaneous fat of buttocks and extremities
Protein status
Extremity muscle bulk and strength
Temporal wasting
Vitamin intake
Changes in skin, mucosa and skin appendages
Skin texture change
Cheilosis and glossitis
Peripheral neuropathy ect

8. Nutritional Assesement Physical Examination (cont . . . )
Trace elements
Sx similar to vitamin def + menal changes

9. Nutritional Assessment History and physical examination
The above determines the risk for malnutrition
Guidelines for identifying patients at risk
Weight
Overweight (BMI 30) and underweight (BMI < 18)
Weight loss more than 10% actual weight
Alcoholics
NPO more than 5 days
Medication with anabolic effect / antinutrient porp

10. Nutritional Assessment Anthropological Markers
Body Mass Index (BMI)
Weight (kg) / height 2
< 18 underweight
< 10 Severely malnouraged
Gross overweight is a risk for malnutrition
Skinfold thickness (SFT)
Measures subcutaneous fat and thus energy reserve ( mm)
Midarm circumference (MAC)
Muscle bulk and therefore somatic protein status (22 – 23 cm)

11. Nutritional Assessment Anthropological Markers (cont . . . )
Bio-electrical Impedance Analysis
Single frequency models unreliable
Dual frequency modes in current clinical assessment
Expensive initial outlay
Accurate measurement of body composition

12. Nutritional Assessment Biochemical anlysis
Serum proteins
Estimates visceral protein reserve
Overall poor reliability due to complex factors
Overall markers include
Total serum protein, albumin, tansferrin and total lymphocyte count
Due to long half live reflects chronic malnutrition
More sensitive markers due to shorter half live
Pre-albumin, retinol binding protein, ceruloplasmin
Reflects acute changes in nutritional status

13. Nutritional Assessment Biochemical anlysis
Nitrogen balance
Measures protein synthesis and breakdown
Protein intake is the sum of all nitrogen intake (Enteral and parenteral)
Protein breakdown is measured by nitrogen excretion in urine, faeces, fistula ect
Calculations
N intake = g protein / 6.25
N output = (urine urea * urine volume/day(l) * 0.028) + losses (3 – 6g)
Balance
Positive = anabolism
Negative = catabolism
Mild 5 – 10g
Moderate 10 – 15g
Severe 15g

14. Calculation of nutritional needs
Energy requirements
TE = NPE + PE
TE = Total energy requirements, NPE = Non-protein energy,PE = protein energy
NPE = Carbohydrate + Lipids
PE = 1.2 – 2 g/kg IBW
NPE = 25 – 30 Kcal/kg IBW
Carbohydrates = 5 g/kg
Lipids = 1 – 1.5 g/kg or 20kcal/kg

15. Complications of overfeeding Carbohydrates
Glucose oxidation rate
No more than 5 mg/kg/min
Delivers 4 cal / g or
Complications
Hyperglycemia and hyper-osmolar states
Hapaic steatosis due to lipogenesis
Increased CO2 and lactate production

16. Complications of overfeeding Lipids
Lipid infusions
Maximum rate 1 – 1.5 g/kg
Given as short, medium and long chain
Delivers 9cal / g
Complications of overfeeding
Hiperlipedaemia and pancreatitis
Fat overload syndrome
Immiunological supression
HSR

17. Complications of overfeeding Proteins
Amino-acid and protein infusion
1.2 – 2 g / kg
Delivers 4 cal / g
Given as variaty of amino-acids
Complication
Azothemia