Water-soluble Vitamins
• Water-soluble vitamins : Thiamin (B1),
Riboflavin (B2), Niacin, Vitamin B6, Folate
(Folic acid), Vitamin B12, Pantothenic acid ,
biotin, choline Vitamin C (Ascorbic acid).
• Fat- soluble vitamins: vit A, vitD , vitE , vitK
• Water-soluble vitamins : Thiamin (B1),
Riboflavin (B2), Niacin, Vitamin B6, Folate
(Folic acid), Vitamin B12, Pantothenic acid ,
biotin, choline Vitamin C (Ascorbic acid).
• Fat- soluble vitamins: vit A, vitD , vitE , vitK
Minerals
•Minerals are simple substances found in the environment that are essential to the body’s functioning.
•Minerals are used to regulate a wide range of body processes, from bone formation to blood clotting.
•Most minerals are either quickly used or lost in waste products, therefore we must eat mineral-rich foods daily to replenish our supply. Iron is an exception –it tends to be kept and recycled by the body.
•Minerals are simple substances found in the environment that are essential to the body’s functioning.
•Minerals are used to regulate a wide range of body processes, from bone formation to blood clotting.
•Most minerals are either quickly used or lost in waste products, therefore we must eat mineral-rich foods daily to replenish our supply. Iron is an exception –it tends to be kept and recycled by the body.
Major Minerals: calcium, phosphorus, magnesium,
potassium, sodium .
• Calcium keeps the nervous system working well
and is needed for blood clotting. Osteoporosis is
disease caused by calcium deficiency.
• Sodium and potassium help regulate the passage
of fluids in and out of cells. Too much sodium in
the diet may aggravate high blood pressure or
hypertension, increasing the risk of heart attack,
stroke or kidney disease. Table salt is one source
of sodium in the diet.
potassium, sodium .
• Calcium keeps the nervous system working well
and is needed for blood clotting. Osteoporosis is
disease caused by calcium deficiency.
• Sodium and potassium help regulate the passage
of fluids in and out of cells. Too much sodium in
the diet may aggravate high blood pressure or
hypertension, increasing the risk of heart attack,
stroke or kidney disease. Table salt is one source
of sodium in the diet.
Trace Minerals: iron, iodine, manganese, zinc, copper, and fluorine
•The majority of the minerals needed for the body to function are only required in very small, or trace amounts.
•Iron is a vital part of hemoglobin – a substance in red blood cells that carries oxygen to all parts of the body. Insufficient iron may cause anemia.
•Iodine is needed for the thyroid gland to function properly. The thyroid gland produces hormones that control how quickly chemical reactions occur in our body. Too little iodine – thyroid gland enlarged. The primary sources are seafood and iodized table salt.
•The majority of the minerals needed for the body to function are only required in very small, or trace amounts.
•Iron is a vital part of hemoglobin – a substance in red blood cells that carries oxygen to all parts of the body. Insufficient iron may cause anemia.
•Iodine is needed for the thyroid gland to function properly. The thyroid gland produces hormones that control how quickly chemical reactions occur in our body. Too little iodine – thyroid gland enlarged. The primary sources are seafood and iodized table salt.
Standards of Nutrition
•Dietary Reference Intakes (DRIs)
–Quantitative estimates of nutrients collectively for proper function and health
•Recommended Daily Allowances (RDA)
•The average daily dietary intake that meets
the nutrient requirement of nearly all healthy persons of a specific sex, age, life style or physiological condition.
•Dietary Reference Intakes (DRIs)
–Quantitative estimates of nutrients collectively for proper function and health
•Recommended Daily Allowances (RDA)
•The average daily dietary intake that meets
the nutrient requirement of nearly all healthy persons of a specific sex, age, life style or physiological condition.
Malnutrition
Definition: loss of the lean body mass and adipose tissue due to insufficient dietary supply
1.primary : inadequate or poor-quality food intake (war or famine).
2.secondary : from diseases that alter food intake or nutrient requirements, metabolism, or absorption.
Two syndrome:
kwashiorkor (malnutrition with edema)
marasmus (malnutrition with marked muscle-wasting).
Definition: loss of the lean body mass and adipose tissue due to insufficient dietary supply
1.primary : inadequate or poor-quality food intake (war or famine).
2.secondary : from diseases that alter food intake or nutrient requirements, metabolism, or absorption.
Two syndrome:
kwashiorkor (malnutrition with edema)
marasmus (malnutrition with marked muscle-wasting).
CAUSES OF malnutrition
Decreased the energy intake ( hypo metabolism)
Economic : poverty, famine
anorexia : nervosa, dementia ,depression cancer , renal failure
Abdominal pain: pancreatitis, intestinal ischemia
Impaired diet transit : benign and malignant esoph. or gastric obstruction
Maldigestion: pancreatic exocrine insufficiency, short bowel syndrome
Malabsorption : small intestinal disease(celiac disease
Decreased the energy intake ( hypo metabolism)
Economic : poverty, famine
anorexia : nervosa, dementia ,depression cancer , renal failure
Abdominal pain: pancreatitis, intestinal ischemia
Impaired diet transit : benign and malignant esoph. or gastric obstruction
Maldigestion: pancreatic exocrine insufficiency, short bowel syndrome
Malabsorption : small intestinal disease(celiac disease
Causes of malnutrition
Increased energy expenditure (hyper metabolism)
Increased BMR: (thyrotoxicosis , fever, cancer trauma , sepsis, surgery,burn)
Excessive physical activity( marathone runner )
Acute and chronic inflammation : T.B ,collagen diseases.
Energy loss :(e.g. glycosuria in diabetes)
Mixed mechanisms
Disseminated cancer
Chronic inflammatory bowel disease (crohns disease
Increased energy expenditure (hyper metabolism)
Increased BMR: (thyrotoxicosis , fever, cancer trauma , sepsis, surgery,burn)
Excessive physical activity( marathone runner )
Acute and chronic inflammation : T.B ,collagen diseases.
Energy loss :(e.g. glycosuria in diabetes)
Mixed mechanisms
Disseminated cancer
Chronic inflammatory bowel disease (crohns disease
Metabolic response to the Starvation :
First day:
•Circulating glucose and FA and TGs , liver and muscle glycogen (1200 Kcal ).
•Lipolysis for the FAs production (65% of energy source )
First few days :
•Lipolysis increase and ketone body production increase
•Gluconeogenesis begin (70 g),15% from protein
2 weeks-30 days :
•Energy conserved , BMR decrease , thyroids hormones decrease , sympath. system decrease
•Lipolysis continue 150g/day (90% on fat)
•Muscle PTN breakdown decrease(20g/day)
First day:
•Circulating glucose and FA and TGs , liver and muscle glycogen (1200 Kcal ).
•Lipolysis for the FAs production (65% of energy source )
First few days :
•Lipolysis increase and ketone body production increase
•Gluconeogenesis begin (70 g),15% from protein
2 weeks-30 days :
•Energy conserved , BMR decrease , thyroids hormones decrease , sympath. system decrease
•Lipolysis continue 150g/day (90% on fat)
•Muscle PTN breakdown decrease(20g/day)
Metabolic response to stress
•High catecholamines ,glucagon , cortisol cytokines , TNF , int 1,6
•Skeletal and visceral PTN catabolism (150 g/d)
•50 % of body protein stores within 3 weeks
•High catecholamines ,glucagon , cortisol cytokines , TNF , int 1,6
•Skeletal and visceral PTN catabolism (150 g/d)
•50 % of body protein stores within 3 weeks
Physiological consequences
1. GIT :
Atrophy of small IN. mucosa
Gastric and pancreatic secretion
Volume of bile and conjugated bile acids decrease
Carbohydrate. and fat malabsorption decrease.
2.CVS:
Myocardial Mass and function decrease
3.Immune system:
Lymphocyte count decrease
Delayed skin hypersensitivity
Decrease production of ABs
1. GIT :
Atrophy of small IN. mucosa
Gastric and pancreatic secretion
Volume of bile and conjugated bile acids decrease
Carbohydrate. and fat malabsorption decrease.
2.CVS:
Myocardial Mass and function decrease
3.Immune system:
Lymphocyte count decrease
Delayed skin hypersensitivity
Decrease production of ABs
4.Respiratory:
•Structural and functional atrophy
5.Bone marrow:
•Decrease lymphocyte and WBC and RBC
6.Renal :
•Decrease mass and function
7.Skin and hair:
•Dry ,thin, wrinkled , hyperkeratosis
•Structural and functional atrophy
5.Bone marrow:
•Decrease lymphocyte and WBC and RBC
6.Renal :
•Decrease mass and function
7.Skin and hair:
•Dry ,thin, wrinkled , hyperkeratosis
8.Endocine
Low insuline
Increase cortisol
Increase growth homone
T3and t4 decrease
Primary gonadal dysfuction
Low insuline
Increase cortisol
Increase growth homone
T3and t4 decrease
Primary gonadal dysfuction
Clinical features:
WT loss
Weakness and, craving for food
muscle wasting
Loss of subcutaneous fat
Leg edema and ascites
Skin dry pale lax, easy packable thin hair
amenorrhea or impotence
Bradycardia Cold cyanosed extremities, pressure sores
distended abdomen, with diarrhea
apathy, depression, loss of the initiative
Features of associated vitamins deficiency
susceptibility to infections
WT loss
Weakness and, craving for food
muscle wasting
Loss of subcutaneous fat
Leg edema and ascites
Skin dry pale lax, easy packable thin hair
amenorrhea or impotence
Bradycardia Cold cyanosed extremities, pressure sores
distended abdomen, with diarrhea
apathy, depression, loss of the initiative
Features of associated vitamins deficiency
susceptibility to infections
INFECTIONS ASSOCIATED WITH PEM Patients:
•Gastroenteritis
•Gram-negative septicemia
•Respiratory infections, especially bronchopneumonia
• viral infection :herpes simplex
•Tuberculosis
•Streptococcal and staphylococcal skin infections
•Helminthic infestation
•Gastroenteritis
•Gram-negative septicemia
•Respiratory infections, especially bronchopneumonia
• viral infection :herpes simplex
•Tuberculosis
•Streptococcal and staphylococcal skin infections
•Helminthic infestation
Nutritional Assessment
•History
•Physical examination
•Anthropometric measurements
•Laboratory investigations
•Functional test
•History
•Physical examination
•Anthropometric measurements
•Laboratory investigations
•Functional test
Nutritional Assessment
History
Dietary Analysis
Dietary history Review foods eaten
Review preparation methods
Evaluate digestive and absorption adequacy
Review supplements taken
Significant weight loss within last 6 months
> 10% loss of body weight
<90% 0f ideal body weight
History
Dietary Analysis
Dietary history Review foods eaten
Review preparation methods
Evaluate digestive and absorption adequacy
Review supplements taken
Significant weight loss within last 6 months
> 10% loss of body weight
<90% 0f ideal body weight
patient History of Weight Loss
Finding Example
Involuntary diet restriction Poverty due to inadequate income
Anorexia Anorexia nervosa, severe depression,
dementia, cancer, chronic renal failure
Inadequate diet selection Chronic alcoholism, strict vegetarianism
Critical illness trauma, burn, major surgery, sepsis
Dysphagia Esophageal obstruction
Nausea, vomiting Gastric or intestinal obstruction
Chronic abdominal pain chronic pancreatitis, intestinal angina
Chronic diarrhea Pancreatic, intestinal mucosal
Finding Example
Involuntary diet restriction Poverty due to inadequate income
Anorexia Anorexia nervosa, severe depression,
dementia, cancer, chronic renal failure
Inadequate diet selection Chronic alcoholism, strict vegetarianism
Critical illness trauma, burn, major surgery, sepsis
Dysphagia Esophageal obstruction
Nausea, vomiting Gastric or intestinal obstruction
Chronic abdominal pain chronic pancreatitis, intestinal angina
Chronic diarrhea Pancreatic, intestinal mucosal
Nutritional AssessmentPhysical Examination
Evidence of muscle wasting
Depletion of subcutaneous fat
Peripheral edema, ascites
Skin changes (easily plucked hair)
Features of Vitamin deficiency
e.g. nail and mucosal changes Anthropometry
Weight for Height comparison
Body Mass Index(BMI)
Triceps-skin fold < (6mm for the men), <(8mm for the women)
Mid arm muscle circumference <(20cm for the men),<(18.5cm for the women)
Evidence of muscle wasting
Depletion of subcutaneous fat
Peripheral edema, ascites
Skin changes (easily plucked hair)
Features of Vitamin deficiency
e.g. nail and mucosal changes Anthropometry
Weight for Height comparison
Body Mass Index(BMI)
Triceps-skin fold < (6mm for the men), <(8mm for the women)
Mid arm muscle circumference <(20cm for the men),<(18.5cm for the women)
Lab investigations
1. Serum visceral protein:
albumin < 30 mg/dl
transferrin < 150 mmol/l
pre-albumin <12 mg/dl
1. Serum visceral protein:
albumin < 30 mg/dl
transferrin < 150 mmol/l
pre-albumin <12 mg/dl
2. vitamin and minerals assays:
tests reflecting specific nutritional deficits e.g. prothrombin time 3.Assessment of immune function:
Total lymphocyte count < 1800 / mm3
Skin anergy testing
Nutritional Assessment
tests reflecting specific nutritional deficits e.g. prothrombin time 3.Assessment of immune function:
Total lymphocyte count < 1800 / mm3
Skin anergy testing
Nutritional Assessment
Functional test
Hand grip dynamometry
Other
Urinary creatinine excretion:
1g of urine creatinine:18.5g of FFM
23mg/kg of ideal body wt./men
18mg/kg of ideal body wt./women
bioelectric impedance analysis
Hand grip dynamometry
Other
Urinary creatinine excretion:
1g of urine creatinine:18.5g of FFM
23mg/kg of ideal body wt./men
18mg/kg of ideal body wt./women
bioelectric impedance analysis
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