PRESCRIBING NUTRITIONAL THERAPY

FOR NON-AMBULATORY PATIENTS

dr. DADANG ARIEF PRIMANA, MSc, SpKO, SpGK-(K)

KSM Nutrisi Klinik, RS. Immanuel, Bandung
 INTRODUCTION

Well balanced nutrition and good

health, two factors that are essential
to excellent performance in daily life

Well balanced diet, healthy diet, adequate

nutrition must satisfy human needs for
energy and all essential nutrients

Krishnaswamy K. Dietary Guidelines for Indians, A Manual National, National Institute of Nutrition,
Hyderabad – 500 007, India. Second Edition. 2011
 INTRODUCTION

Adequate nutrition requires that all

nutrients, carbohydrates, lipids, proteins,
minerals, vitamins and water are consumed
in sufficient amounts for :
- normal organ development and
function
- repair of body tissues
- combating stress and disease
Nishida C. The Joint WHO/FAO Expert consultation on diet, nutrition and the prevention of chronic
diseases: process, product, and policy implications. Public Health Nutr. 2004;7
INTRODUCTION

Good Food is Good Medicine!

 INTNRODUCTION

The patients who received adequate

nutritional therapy had a shorter hospital
stay compared with those patients who
did not receive adequate nutritional
therapy

Neumayer LA, Smout RJ, Horn HG, et al. Early and sufficient feeding reduces
length of stay and charges in surgical patients. J Surg Res. 2001;95:73-77
 INTNRODUCTION
Nutrition therapy
- to provide nutrition therapy consistent
with the patient’s medical condition
- to prevent and treat nutrient deficiencies
- to provide doses of nutrients compatible
with the existing metabolism
- to avoid complications
- to improve patient outcomes
Cerra, FB. Applied nutrition in ICU patients: a consensus statement of the American College
of Chest Physicians. Chest, 1997, 111,769-778
ENERGY BALANCE

Energy balance is defined as the state

achieved when energy intake equals
energy expenditure and is considered to
be dynamic and not static, process in
which altering one component of the energy
balance paradigm can affect the physiologi-
cal and biological components of the other
in an unpredictable or unintended way

Hill JO. Energy balance and obesity, Circulation, 2012;126:126–32.

 ENERGY BALANCE

The basic components of energy balance

include energy intake, energy
expenditure and energy storage

Energy balance is achieved when the

energy intake equals energy expenditure

Hafekost K. Tackling overweight and obesity: does the public health message match the science?,
BMC Med, 2013;11:41.
Hill JO. Energy balance and obesity, Circulation, 2012;126:126–32.
 ENERGY BALANCE

ENERGY INTAKE ENERGY EXPENDITURE

ENERGY BALANCE

Figure . The energy balance.

 ENERGY BALANCE

Figure. The energy balance “sweet spot.”

Economos CD. Food and Physical Activity Environments An Energy Balance Approach for Research and
Practice. Am J Prev Med 2015;48(5):620–629
 ENERGY BALANCE
The concept of energy balance may be
used to demonstrate how bodyweight will
change over time in response to changes in
energy intake and expenditure.

Hafekost K. Tackling overweight and obesity: does the public health message match the science?,
BMC Med, 2013;11:41.
Hill JO. Energy balance and obesity, Circulation, 2012;126:126–32.
 ENERGY BALANCE
Theoretically, an individual can achieve
energy balance in multiple ways
The way energy balance is achieved by
characteristics of human physiology

This system includes afferent signals from the

periphery about the state of energy stores
and efferent signals that affect energy intake
and expenditure

Sandoval D. The Integrative Role of CNS Fuel-Sensing Mechanisms in Energy Balance and Glucose
Regulation. Ann Rev Physiology. 2008; 70
 ENERGY BALANCE

Figure. Key factors that regulate and influence energy balance, which can ultimately
influence weight, body composition, and overall health.
Manore MM. Energy Balance at a Crossroads: Translating the Science into Action. Journal of The Academy
of Nutrition and Dietetics, 2014, 114, 7
 ENERGY INTAKE

Components of energy intake includes

three major macronutrient groups are
carbohydrate, protein, and fat

Carbohydrates and fats provide most of the

dietary energy intake, whereas the fraction of
dietary energy that is provided by protein intake
is relatively small
Hill, J.O. Using the energy gap to address obesity: a commentary. J. Am. Diet. Assoc. 2009, 109,
Naslund. The gut and food intake: an update for surgeons. J Gastrointest Surg 2001;5:556-67.
 ENERGY INTAKE

Macronutrients all contribute to dietary

energy intake

The estimated Acceptable Macronutrient

Distribution Ranges related to reduced risk of
chronic disease are:
• 20–35% of total energy intake from fat
• 45–65% from carbohydrate
• 15–25% from protein.
Australian Government, National Health and Medical Research Council, Depart. of Health and Ageing. Eat
for Health, Australian Dietary Guidelines. Providing the scientific evidence for healthier Australian diets. 2013
 ENERGY INTAKE
Carbohydrate energy utilisation of a given
food combination response will depend on
its degree of :
- polymerization (mono, di, polysaccharides)
- polysaccharides component (amilose and
amilopectin content)
- colonic fermentation
- amount of dietary fibre and resistant starch
Englyst1 KN. Nutritional characterization and measurement of dietary carbohydrates. Er J Cl Nutr. 2007. 61
 ENERGY INTAKE
From a physiologic standpoint, the metabolic
effects of excess carbohydrate energy are
related not only to its own metabolism but
also to a variable effect on fat storage

FAO. Carbohydrates in human nutrition. Food and Agriculture Organization, Food and Nutrition Paper No. 66. Report
of a Joint FAO/WHO Expert Consultation. Rome, 1998
Englyst1 KN. Nutritional characterization and measurement of dietary carbohydrates. European Journal of Clinical
 ENERGY INTAKE

A wide range of fat intake is generally

well tolerated by most individuals.
Current national guidelines recommend
limiting fat intake to less than 30% of
total kcals.

A higher percent fat intake may be desired for

patients with poor appetites/ limited food
intake to increase caloric density of foods
Australian Government, National Health and Medical Research Council, Depart. of Health and Ageing. Eat
for Health, Australian Dietary Guidelines. Providing the scientific evidence for healthier Australian diets. 2013
 ENERGY INTAKE
Fat intake :
- the total amount of fat
- the number of carbons
- the degree of saturation (safa, mufa orpufa)
- the presence of double bonds in positions
n-9, n-6, n-3, and their respective ratios
are significant in terms of energy balance and
health effects
Connor W. Differential mobilization of fatty acids from adipose tissue. Journal of Lipid Research 1996; 37: 290–8.
DeLany J. Differential oxidation of individual dietary fatty acids in humans. American Journal of Clin Nutri 2000; 72:
 ENERGY INTAKE
Differences in chemical structure of lipids have
a direct effect on lipoprotein metabolism, fuel
partitioning to oxidation or storage, insulin
resistance and other metabolic effects of excess
fat energy

• Saturated Monounsaturated Polyunsaturated

• - Animal Fats - Olive Oil - Corn
• - Lard - Canola Oil - Soybean
• - Butter - Peanut - Cottonseed
• - Palm - Avocado - Safflower
• - Palm Kernal - Sunflower
• - Coconut (lauric acids-C12, myristic acids-C14 - Fish Oils (Omega 3 Oils)

DeLany J. Differential oxidation of individual dietary fatty acids in humans. American Journal of Clin Nutri 2000; 72:
 ENERGY INTAKE

Protein needs may vary greatly with the

metabolic status of the patient
Protein requirements are slightly
increased in patients

The average patient receiving nutritional

therapy requires 0.8 - 2.5 g protein/kg usual
body weight/day.
Australian Government, National Health and Medical Research Council, Depart. of Health and Ageing. Eat
for Health, Australian Dietary Guidelines. Providing the scientific evidence for healthier Australian diets. 2013
 ENERGY INTAKE
High protein meals have the capacity to
increase short-term satiety
Increased aminoacid oxidation in the gut and
liver induces satiety and satiation responses via
afferent vagal fibres

Barkeling B. Effects of a high protein meal (meat) and a high carbohydrate meal (vegetarian) on satiety measured by
automated computerized monitoring of subsequent food intake, motivation to eat and food preferences. International
Journal of Obesity 1990; 14: 743–51.
 ENERGY INTAKE

Once ingested, the net absorption of the

major macronutrient groups, carbohydrate,
protein, and fat is variable and incomplete,
with fecal losses

Digestibility depends on the composition of

the food item and on its content of fiber and
other indigestible components.

Hill, J.O. Using the energy gap to address obesity: a commentary. J. Am. Diet. Assoc. 2009, 109,
Naslund. The gut and food intake: an update for surgeons. J Gastrointest Surg 2001;5:556-67.
 ENERGY INTAKE
The net absorption of dietary energy
components varies among individuals and is
dependent on the specific foods eaten, how
they are prepared, and intestinal factors.

The variability in absorptive efficiency depends

on any additional factors (gut flora, food
preparation, diet composition), which may
explain the individual differences in metaboliz-
able energy
Hill, J.O. Using the energy gap to address obesity: a commentary. J. Am. Diet. Assoc. 2009, 109,
Naslund. The gut and food intake: an update for surgeons. J Gastrointest Surg 2001;5:556-67..
 ENERGY INTAKE

Figure Diagram showing the flow of energy through the body.

FAO. Food Energy—Methods of Analysis and Conversion Factors. FAO: Rome. 2003
Livesey G. A perspective on food energy standards for nutrition labelling. Br J Nutr. 2001. 85,.
Warwick PM,. Point of view: energy factors for food labelling and other purposes should be derived in a consistent
fashion for all food components. Br J Nutr .2000.84, 897–902.;
ENERGY INTAKE

Energi
glikogenolisis

lipolisis
glikolisis

glukoneogenesis
glukoneogenesis

proteolisis
ENERGY INTAKE
 ENERGY EXPENDITURE
Energy expenditure is the general term used to
describe the number of calories consumed
during a given period of time, usually 24 hours
(energy requirement)
The determination of a energy expenditure or
energy requirements is an essential component
of nutrition therapy, ensuring that the patient's
nutritional needs are met without significant
underfeeding or overfeeding
Laaban JP. Nutritional status of patients with chronic obstructive pulmonary disease
and acute respiratory failure. Chest. 1993;103:1362-1368
 ENERGY EXPENDITURE

The nutritional therapy or nutritional

treatment of patients based on specific
caloric requirements is important

The ability to predict resting energy

expenditure in a given individual during
illness is very difficult.
Barak N. Evaluation of stress factors and body weight adjustments currently used to estimate
energy expenditure in hospitalized patients. JPEN 2002;26(4):231-238) .
 ENERGY EXPENDITURE
Energy expenditure or energy requirements
are difficult to predict in patients, due to their
disease processes, inflammatory response, and
other variables.

Accurate determination of energy

expenditure is essential to avoid feeding-
associated adverse effects

Barak N. Evaluation of stress factors and body weight adjustments currently used to estimate
energy expenditure in hospitalized patients. JPEN 2002;26(4):231-238)
Psota T. Measuring energy expenditure in clinical populations. Eur J Clin Nutr. 2013. 67. .
 ENERGY EXPENDITURE
The key factors that may regulate the energy
expenditure side of the energy balance are:
- activities of daily
- resting metabolic rate
- metabolic cost of living
digestion - amount of physical
- absorption and activity
- thermogenesis
metabolism
- body weight
- disease condition
- body composition
Morton GJ. Central nervous system control of food intake and body weight. Nature 2006;443.
 ENERGY EXPENDITURE
Many methods are available for measure-
ment of resting energy expenditure, but
they all have limitations

There are two ways to calculate

resting energy expenditure by
measurement or pedictive
equations (estimates)
Barak N. Evaluation of stress factors and body weight adjustments currently used to estimate
energy expenditure in hospitalized patients. JPEN 2002;26(4):231-238) .
Volp ACP. Energy expenditure: components and evaluation methods. Nutr Hosp. 2011.26
 ENERGY EXPENDITURE

The most accurate method for determining

energy requirement is therefore by
measurement energy expenditure, such as
direct calorimetry, indirect calorimetry

The most popular predictive equation is

the Harris-Benedict formula
Barak N. Evaluation of stress factors and body weight adjustments currently used to estimate
energy expenditure in hospitalized patients. JPEN 2002;26(4):231-238) .
Volp ACP. Energy expenditure: components and evaluation methods. Nutr Hosp. 2011.26
ENERGY EXPENDITURE

Indirect calorimetry is the gold standard

method of measuring Resting Energy
Expenditure

Indirect calorimetry has higher accuracy

but indirect calorimetry is more
expensive, require trained personal, time-
consuming, and cumbersome.
ENERGY EXPENDITURE
The indirect calorimetry
ENERGY EXPENDITURE
The indirect calorimetry

36
ENERGY EXPENDITURE
The indirect calorimetry

37
ENERGY EXPENDITURE
The indirect calorimetry

38
 ENERGY EXPENDITURE

Resting energy expenditure is commonly

estimated from standard equations such as
the Harris-Benedict Equation to provide
calorie intake recommendations.

Calculated resting energy expenditure values

can be significantly higher or lower than
measured resting energy expenditure values

Volp ACP. Energy expenditure: components and evaluation methods. Nutr Hosp.
2011.26
 ENERGY EXPENDITURE
Harris Benedict Equation (HBE)
Men = 66.47 + (13.75 x wt in kg) + (5 x ht in
cm) – (6.76 x age)
Women = 655.1 + (9.56 x wt in kg) + (1.85 x ht
in cm) – (4.68 x age)
The Harris-Benedict equation have been shown to be
inaccurate in a variety of clinical settings and vary
considerably from measured values.
Barak N. Evaluation of stress factors and body weight adjustments currently used to estimate
energy expenditure in hospitalized patients. JPEN 2002;26(4):231-238) .
Mann S. Measured and predicted caloric expenditure in the acutely ill. Crit Care Med 1985;13
Pirat A, Tucker AM, Nates JL. Comparison of Measured Versus Predicted Energy
Requirements in Critically Ill Cancer Patients [Respir Care 2009;54(4):487–494. 41
 ENERGY EXPENDITURE
The rule of thumb
The rule of thumb is simplest recommenda-
tions advocate a fixed amount of calories/
kilogram/body weight
These guidelines are indeed very simple
The most common rule of thumb proposed
implies a caloric target around 25-30 kcal/kg of
body weight with adaptation for a body mass
index outside the normal range
Barak N. Evaluation of stress factors and body weight adjustments currently used to estimate
energy expenditure in hospitalized patients. JPEN 2002;26(4):231-238) .
 ENERGY STORE
When energy intake exceeds energy
expenditure, energy is stored
Components of energy storage is triglycerides,
which are present within adipose tissue, are the
body’s major fuel reserve

Figure. A simple model implicating adipose tissue in the regulation of food

intake and energy metabolism. CNS, central nervous system.

Hirsch J. Diet composition and energy balance in humans Am J Clin Nutr 1998;67.
 ENERGY STORE

Most fat is stored directly into adipose tissue

Body has unlimited ability to store fat

Most carbohydrate is used as a energy source

Excessive carbohydrate intake will be
converted into fat

Schrauwen P. Human uncoupling proteins and obesity. Obes Res 1999;7:97-105.

Ravussin E. Relationship of genetics, age, and physical fitness to daily energy expend and fuel utilization. Am J Clin Nutr 1989;49
 ENERGY STORE
Protein is primarily used for tissue synthesis
Adults generally consume more protein than
needed for tissue synthesis and some protein
will be converted into fat

Schrauwen P. Human uncoupling proteins and obesity. Obes Res 1999;7:97-105.

Ravussin E. Relationship of genetics, age, and physical fitness to daily energy expend and fuel utilization. Am J Clin Nutr 1989;49
 NUTRITION THERAPY
Adequate nutrition therapy plays an
important role in maintaining optimal health
The consequences of malnutrition have been
well documented and contribute significantly
to morbidity and mortality
Accurate assessment of energy requirements
and provision of optimal nutrition therapy
through the appropriate route is an important
goal of patients
ASPEN Board of Directors, Clinical Guidelines Task Force. Guidelines for the use of parenteral
and enteral nutrition in adult and pediatric patients. JPEN. 2002;26:Suppl:1SA-138SA
 NUTRITION THERAPY
Energy requirements are often not
reached, due to
- intestinal dysfunction as part of the critical
illness
- the administered medication that affects
the gastrointestinal tract
- frequent interruptions of enteral feeding
- the need for fluid restriction
ASPEN Board of Directors, Clinical Guidelines Task Force. Guidelines for the use of parenteral
and enteral nutrition in adult and pediatric patients. JPEN. 2002;26:Suppl:1SA-138SA
 NUTRITION THERAPY

The oral route is always the preferred

route for providing nutritional intake
Many different types of oral diets are
available

In addition, commercially prepared liquid

oral supplements can be used in conjunc-
tion with an oral diet to promote adequate
nutrient intake
ASPEN Board of Directors, Clinical Guidelines Task Force. Guidelines for the use of parenteral
and enteral nutrition in adult and pediatric patients. JPEN. 2002;26:Suppl:1SA-138SA
 NUTRITION THERAPY

Enteral nutrition is indicated when there is an

inability to ingest adequate nutrients by
mouth and where the gastrointestinal tract is
normal

When selecting an appropriate enteral

formulation both formula characteristics
and patient-specific factors should be
considered
ASPEN Board of Directors, Clinical Guidelines Task Force. Guidelines for the use of parenteral
and enteral nutrition in adult and pediatric patients. JPEN. 2002;26:Suppl:1SA-138SA
 NUTRITION THERAPY

Enteral formula variables include:

- digestibility of the nutrients
- availability of the nutrients
- nutritional adequacy
- viscosity
- osmolality
- ease of use, and cost
ASPEN Board of Directors, Clinical Guidelines Task Force. Guidelines for the use of parenteral
and enteral nutrition in adult and pediatric patients. JPEN. 2002;26:Suppl:1SA-138SA
 NUTRITION THERAPY

Enteral nutrition should be withheld in:

- patients who are hypotensive
- patients for whom catecholamine
agents are being initiated
- patients for whom escalating doses are
required to maintain hemodynamic
stablity
ASPEN Board of Directors, Clinical Guidelines Task Force. Guidelines for the use of parenteral
and enteral nutrition in adult and pediatric patients. JPEN. 2002;26:Suppl:1SA-138SA
 NUTRITION THERAPY

Parenteral nutrition is used where there is:

- indicated when normal metabolic and
nutritional needs are not sufficiently
provided by enteral nutrition
- failure of gut function (with obstruction,
ileus, dysmotility, severe malabsorption)

ASPEN Board of Directors, Clinical Guidelines Task Force. Guidelines for the use of parenteral
and enteral nutrition in adult and pediatric patients. JPEN. 2002;26:Suppl:1SA-138SA
 NUTRITION THERAPY

Parenteral nutrition solutions are

prescribed daily in association with the
patient’s fluid and electrolyte requirements,
both of which are considered when the
daily plasma biochemical results are
available
ASPEN Board of Directors, Clinical Guidelines Task Force. Guidelines for the use of parenteral
and enteral nutrition in adult and pediatric patients. JPEN. 2002;26:Suppl:1SA-138SA
 NUTRITION THERAPY
Daily calculations of parenteral nutrition
for each patient :
- fluids volume (ml/kg)
- energy (kcal/kg)
- protein (gram/kg)
- fat (gram/kg)
- electrolytes (mEq/kg)
- glucose load (mg/kg/minute)
ASPEN Board of Directors, Clinical Guidelines Task Force. Guidelines for the use of parenteral
and enteral nutrition in adult and pediatric patients. JPEN. 2002;26:Suppl:1SA-138SA
CONCLUSION

Balance energy requires that all nutrients,

carbohydrates, lipids, proteins, minerals,
vitamins and water are consumed in
sufficient amounts for normal organ
development and function, repair of body
tissues, and combating stress and disease.
CONCLUSION

Accurate assessment of energy require-

ments and provision of optimal nutrition
therapy through the appropriate route is
an important goal of patients
dr. DADANG ARIEF PRIMANA, MSc, SpKO, SpGK(K)
KSM Nutrisi Klinik, RS. Immanuel Bandung

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YOU