Nutritional requirements

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  • Harrison's Internal Medicine Chapter 70. Nutritional Requirements and Dietary Assessment Nutritional Requirements and Dietary Assessment: Introduction Nutrients are substances that must be supplied by the diet because they are not synthesized in the body in sufficient amounts. Nutrient requirements for groups of healthy persons have been determined experimentally. For good health we require energy-providing nutrients (protein, fat, and carbohydrate), vitamins, minerals, and water.

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  • Nutritional Status Assessment Full nutritional status assessment is reserved for seriously ill patients and those at very high nutritional risk when the cause of malnutrition is still uncertain after initial clinical evaluation and dietary assessment. It involves multiple dimensions, including documentation of dietary intake, anthropometric measurements, biochemical measurements of blood and urine, clinical examination, health history, and functional status. For further discussion of nutritional assessment, see Chap. 72.

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  • Estimated Average Requirement When florid manifestations of the classic dietary deficiency diseases such as rickets, scurvy, xerophthalmia, and protein-calorie malnutrition were common, nutrient adequacy was inferred from the absence of their clinical signs. Later, it was determined that biochemical and other changes were evident long before the clinical deficiency became apparent. Consequently, criteria of nutrient adequacy are now based on biologic markers when they are available.

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  • Physiologic Factors Growth, strenuous physical activity, pregnancy, and lactation increase needs for energy and several essential nutrients, including water. Energy needs rise during pregnancy, due to the demands of fetal growth, and during lactation, because of the increased energy required for milk production. Energy needs decrease with loss of lean body mass, the major determinant of REE. Because both health and physical activity tend to decline with age, energy needs in older persons, especially those over 70, tend to be less than those of younger persons.

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  • Nutrient requirements for optimum health and function of aging physiological systems often are quite distinct from those required for young ones. Recognition and understanding of the special nutrition problems of the aged are being intensively researched and tested, especially due to the increases in the elderly in the general population. In developed countries, economic restrictions and physical inactivity during aging can significantly reduce food intakes, contributing to nutritional stresses and needs. Many disease entities and cancers are found with higher frequency in the aged.

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  • Nutritional Biochemistry takes a scientific approach to nutrition. It covers not just "whats"--nutritional requirements--but why they are required for human health, by describing their function at the cellular and molecular level. Each case study either leads to a subsequent discovery or enables an understanding of the physiological mechanisms of action of various nutrition-related processes. The text is "picture-oriented" and the commentary is directed towards explaining graphs, figures, and tables. ...

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  • Water For adults, 1.0–1.5 mL water per kcal of energy expenditure is sufficient under usual conditions to allow for normal variations in physical activity, sweating, and solute load of the diet. Water losses include 50–100 mL/d in the feces, 500–1000 mL/d by evaporation or exhalation, and, depending on the renal solute load, ≥1000 mL/d in the urine. If external losses increase, intakes must increase accordingly to avoid underhydration. Fever increases water losses by approximately 200 mL/d per °C; diarrheal losses vary but may be as great as 5 L/d with severe diarrhea.

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  • Note: This table presents recommended dietary allowances (RDAs) in bold type and adequate intakes (AIs) in ordinary type. RDAs and AIs may both be used as goals for individual intake. RDAs are set to meet the needs of almost all individuals (97 to 98%) in a group. For healthy breastfed infants, the AI is the mean intake. The AI for other life stage and gender groups is believed to cover needs of all individuals in the group, but lack of data or uncertainty in the data prevent being able to specify with confidence the percentage of individuals covered by...

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  • Acute Care Settings Acute care settings, anorexia, various diseases, test procedures, and medications can compromise dietary intake. Under such circumstances, the goal is to identify and avoid inadequate intake and ensure appropriate alimentation. Dietary assessment focuses on what patients are currently eating, whether they are able and willing to eat, and whether they experience any problems with eating. Dietary intake assessment is based on information from observed intakes; medical record; history; clinical examination; and anthropometric, biochemical, and functional status.

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  • The vitamins are a chemically disparate group of compounds whose only common feature is that they are dietary essentials that are required in small amounts for the normal functioning of the body and maintenance of metabolic integrity.Metabolically, they have diverse functions, such as coenzymes, hormones, antioxidants, mediators of cell signaling, and regulators of cell and tissue growth and differentiation.

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  • Early interest in selenium by nutritionists concerned its high concentration in certain range plants and the consequent toxicosis in animals that grazed those plants. More recently, the essential nature of selenium has become the center of attention, and this element is now known to be required by laboratory animals, food animals (including fish), and humans. Its role as an integral feature of glutathione peroxidase has been established, and other possible functions are under active investigation.

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  • The food we eat has a major effect on our physical health and psychological wellbeing. An understanding of the way in which nutrients are metabolized, and hence of the principles of biochemistry, is essential for an understanding of the scientific basis of what we would call a prudent or healthy diet. My aim in the following pages is to explain both the conclusions of the many expert committees that have deliberated on the problems of nutritional requirements, diet and health over the years and also the scientific basis on which these experts have reached their conclusions.

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  • Intravenous nutrition (IVN), also known as parenteral nutrition (PN), involves the administration of nutrients, electrolytes, minerals and fluid directly into patients’ veins. It is used in patients whose gastrointestinal absorption of food and/or fluids is inadequate, unsafe or inaccessible. Infusing a mixture of nutrients and fluid, however, is not without risk.

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  • Nutritional History A nutritional history is directed toward identifying underlying mechanisms that put patients at risk for nutritional depletion or excess. These mechanisms include inadequate intake, impaired absorption, decreased utilization, increased losses, and increased requirements of nutrients. Individuals with the characteristics listed in Table 72-3 are at particular risk for nutritional deficiencies.

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  • Efficacy of SNS in Different Disease States Efficacy studies have shown that malnourished patients undergoing major thoracoabdominal surgery benefit from SNS. Critical illness requiring ICU care including major burns, major trauma, severe sepsis, closed head injury, and severe pancreatitis [positive CT scan and Acute Physiology and Chronic Health Evaluation II (APACHE II) 10] all benefit by early SNS, as indicated by reduced mortality and morbidity. In critical illness, initiation of SNS within 24 h of injury or ICU admission is associated with a ~50% reduction in mortality.

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  • Disease-Specific Nutritional Support SNS is basically a support therapy and is primary therapy only for the treatment or prevention of malnutrition. Certain conditions require modification of nutritional support because of organ or system impairment. For instance, in nitrogen accumulation disorders, protein intake may need to be reduced. However, in renal disease, except for brief periods of several days, protein intakes should approach requirement levels of at least 0.8 g/kg or higher up to 1.2 g/kg as long as the blood urea nitrogen does not exceed 100 mg/dL.

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  • Table 73-10 Enteral Formulas Composition Characteristics Clinical Indications STANDARD ENTERAL FORMULA 1. Complete dietary products (+)a Suitable for most patients requiring tube feeding; some can be a. Caloric density 1 kcal/mL used orally b. Protein ~14% cals, caseinates, soy, lactalbumin c. CHO ~60% cals, hydrolyzed corn starch, maltodextrin, sucrose d. Fat ~30% cals, corn, soy, safflower oils e. Recommended daily intake of all minerals and vitamins in 1500 kcal/d f. Osmolality (mosmol/kg): ~300 MODIFIED ENTERAL FORMULAS 1. Caloric density 1.

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  • Harrison's Internal Medicine Chapter 72. Malnutrition and Nutritional Assessment Malnutrition and Nutritional Assessment: Introduction Malnutrition can arise from primary or secondary causes, with the former resulting from inadequate or poor-quality food intake and the latter from diseases that alter food intake or nutrient requirements, metabolism, or absorption. Primary malnutrition occurs mainly in developing countries and under conditions of war or famine.

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  • Energy Requirements Total energy expenditure comprises resting energy expenditure (two-thirds) plus activity energy expenditure (one-third) (Chap. 72). Resting energy expenditure includes the calories necessary for basal metabolism at bed rest. Activity energy expenditure represents one-fourth to one-third of the total, and the thermal effect of feeding is about 10% of the total energy expenditure. For normally nourished healthy individuals, the total energy expenditure is about 30– 35 kcal/kg.

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  • Protein or Amino Acid Requirements Although the recommended dietary allowance for protein is 0.8 g/kg per d, maximal rates of repletion occur with 1.5 g/kg in the malnourished. In the severely catabolic patient, this higher level minimizes protein loss. In patients requiring SNS in the acute care setting, at least 1 g/kg is recommended, with greater amounts up to 1.5 g/kg as volume, renal, and hepatic tolerances allow. The standard parenteral and enteral formulas contain protein of high biologic value and meet the requirements for the eight essential amino acids.

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