OBJECTIVES

Energy Metabolism and Normal Nutritional R Requirements i t

FERNANDO L. LOPEZ, MD, FPCS Professor of Surgery UST Department of Surgery

To review normal protein, carbohydrate and lipid metabolism To understand the mechanisms that regulate substrate utilization and energy production To demonstrate methods for calculating nutritional requirements

NUTRIENTS

Glucose Metabolism
Glucose Glucose Cori Cycle Pyruvate Lactate Lactate
Lieberman MA, Vester JW. Carbohydrates. In: Nutrition and Metabolism in the Surgical Patient. Boston, MA: Little, Brown and Company;1996:203-236. MITOCHONDRIA

Protein Carbohydrates enteral parenteral Lipids Water Vitamins

Water soluble Fat soluble

4 kcal / g 4 kcal / g 3.4 kcal / g 9 kcal / g

CYTOPLASM

Pyruvate
AcetylCoA

Krebs Cycle

ATP

Minerals
Electrolytes Trace elements and ultra trace minerals

Fatty Acid Metabolism

ESSENTIAL
CAPILLARY

Amino Acids

CONDITIONALLY ESSENTIAL

CYTOPLASM Fatty Acids

Carnitine
MITOCHONDRIA

Triglycerides

Fatty Acids Fatty Acids + Glycerol ATP

Oxidation

Triglycerides

Leucine Lysine Valine Threonine Isoleucine Phenylalanine Methionine Histidine Tryptophan

Glutamine Arginine Alanine Tyrosine Aspartic Acid Glutamic Acid Cysteine Glycine Serine Proline

NON-ESSENTIAL

Fischer JE, ed. Nutrition and metabolism in the surgical patient. Boston, MA: Little, Brown and Company; 1996.

Fischer JE, ed. In: Nutrition and Metabolism in the Surgical Patient. 1st ed. Lippincott Williams and Wilkins Publishers; 1996.

Chemical Structure of an Amino Acid

Nitrogen Balance

COOH

NB = IN (UN + RNL)
NB: IN: UN: RNL: Nitrogen Balance Ingested Nitrogen 24-Hour Urine Nitrogen Remaining Nitrogen Loss (3.1 g/d)

R
NH3
Fischer JE, ed. In: Nutrition and Metabolism in the Surgical Patient. 1st ed. Lippincott Williams and Wilkins Publishers; 1996.

Respiratory Quotient (RQ)

Respiratory Quotient (RQ)

RQ

RQ =
RQ: VCO2: VO2:

VCO2 VO 2

Glucose oxidation 1 glucose + 6 O2 = 6 CO2 + 6 H20 Fat oxidation 1 palmitate + 23 O2 = 16 CO2 + 16 H2O

6/6 = 1.0 16/23 = 0.7

Respiratory Quotient CO2 Produced Oxygen Consumed

Protein oxidation 4.1/5.1 = 0.8 1 amino acid + 5.1 O2 = 4.1 O2 + 2.8 H2O Lipogenesis > 1.0 8.0

Nutrient Utilization

Excess Glucose Supply

Regulation Nutrient availability Hormonal environment Inflammatory state

Glucose
Glucose

CO2 CYTOPLASM Lipogenesis Triglycerides Acetyl CoA

MITOCHONDRIA

Pyruvate

Pyruvate
Acetyl CoA

Krebs Cycle

ATP

Excess Fatty Acid Supply

Free Fatty Acids
CYTOPLASM F tt Acids Fatty A id
Carnitine
MITOCHONDRIA

Inflammatory Response

Glucose Glucose

CYTOPLASM

Ketones low insulin high insulin

Fatty Acids
Oxidation

Cori Cycle

MITOCHONDRIA

Pyruvate Lactate

Pyruvate
TNF IL1 IL6

Krebs Cycle

ATP

Acetyl CoA Lactate

Acetyl CoA

Triglycerides

BLOCKAGE

Inflammatory Response

Energy Substrate Utilization

CAPILLARY

CYTOPLASM Fatty Acids

Carnitine

Triglycerides TNF Fatty Acids + Glycerol

TNF, IL-1
MITOCHONDRIA

Fasting state: Depends p on nutrient availability y In stress: Depends on hormonal environment and inflammatory response

Fatty Acids
Oxidation

ATP

Triglycerides

Body Composition
Weight (kg) Total Water (L) Intracellular Extracellular Total Solids (kg) Fat (kg) BCM Protein (kg) Minerals (kg) 70 42 28 14 28 12.5 12.5 3 60 31 19 12 28.8 17 9 3
BCM = Body Cell Mass

Malnutrition

Ideal Weight Actual Weight g

In malnutrition, energy expenditure must be calculated based on actual body weight.

Obesity

Calculating Basal Energy Expenditure

Ideal Weight Actual Weight g

Harris-Benedict Equation Variables gender, weight (kg), height (cm), age (years)
Men:

66.47 + (13.75 x weight) + (5 x height) (6.76 x age)

Women:

655.1 + (9.56 x weight) + (1.85 x height) (4.67 x age)

Calorie requirement = BEE x activity factor x stress factor

In obesity, energy expenditure must be calculated on ideal weight.

Calorie Calculation

Rule of Thumb Calorie requirement = 25 to 30 kcal/kg/day

Metabolic Response to Starvation and Trauma: Nutritional Requirements

Objectives
Muscle

Fasting Early Stage

Alanine / Pyruvate

Explain the differences between metabolic responses to starvation and trauma Explain the effect of trauma on metabolic rate and substrate utilization Determine calorie and protein requirements during metabolic stress

Glucose

Brain

Glutamine Glycerol

Gluconeogenesis Ketogenesis
Ketones Liver

Fat

AGL

Ureagenesis
Ketones NH3 Intestine Urea

Kidney

Fasting Late Stage

Muscle

Metabolic Reaction to Starvation

Brain

Alanine / Pyruvate Glutamine Glycerol

Glucose

Hormone Norepinephrine o ep ep e Norepinephrine Epinephrine Thyroid Hormone T4

Source Sympathetic Nervous System Adrenal Gland Adrenal Gland Thyroid Gland (changes to T3 peripherally)

Change in Secretion

Gluconeogenesis K Ketogenesis i
Ketones Liver

Fat AGL

Ureagenesis
Ketones NH3 Intestine Urea

Kidney

Landberg L, et al. N Engl J Med 1978;298:1295.

Energy Expenditure in Starvation

12

Metabolic Response to Trauma

Nitrogen Excret tion (g/day)

Ebb Phase
8

Flow Phase

Normal Range

Partial Starvation Total Starvation

Energy Expen nditure

10

20

30

40

Time

Days
Long CL et al. JPEN 1979;3:452-456

Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55

Metabolic Response to Trauma: Ebb Phase

Metabolic Response to Trauma: Flow Phase

Characterized by hypovolemic shock Priority is to maintain life/homeostasis

Cardiac output Oxygen O consumption ti Blood pressure Tissue perfusion Body temperature Metabolic rate

Catecholamines Glucocorticoids Glucagon g Release of cytokines, lipid mediators Acute phase protein production

Cuthbertson DP, et al. Adv Clin Chem 1969;12:1-55 Welborn MB. In: Rombeau JL, Rolandelli RH, eds. Enteral and Tube Feeding. 3rd ed. 1997

Cuthbertson DP, et al. Adv Clin Chem 1969;12:1-55 Welborn MB. In: Rombeau JL, Rolandelli RH, eds. Enteral and Tube Feeding. 3rd ed. 1997

Metabolic Response to Trauma

Metabolic Response to Trauma

28

Fatty Deposits
Endocrine Response

Nitrogen Excretion (g/day)

Fatty Acids

24 20 16 12 8 4 0 10 20 Days 30 40

Liver & Muscle (glycogen) Muscle (amino acids)

Glucose Amino Acids

Long CL, et al. JPEN 1979;3:452-456

Severity of Trauma: Effects on Nitrogen Losses and Metabolic Rate

Major Surgery
Nitrogen Loss in Urine

Metabolic Response to Starvation and Trauma

Starvation Trauma or Disease wasted wasted rapid

Moderate to Severe Burn

Severe Infection Sepsis Elective Surgery

Metabolic rate y fuels Body Body protein Urinary nitrogen Weight loss

conserved conserved slow

Basal Metabolic Rate Adapted from Long CL, et al. JPEN 1979;3:452-456

The body adapts to starvation, but not in the presence of critical injury or disease.
Popp MB, et al. In: Fischer JF, ed. Surgical Nutrition. 1983.

Calorie Distribution Shift in Catabolism NORMAL

25% 15%

Determining Calorie Requirements

CATABOLIC
30% 25%

Fat

Protein

Fat

Protein

Indirect calorimetry Harris-Benedict x stress factor x activity factor 25-30 kcal/kg body weight/day

CHO
60%

CHO
45%

Metabolic Response to Starvation and Trauma: Nutritional Requirements

Injury Minor surgery Long bone fracture Cancer Peritonitis/sepsis Severe infection/multiple trauma Multi-organ failure syndrome Burns Activity Confined to bed Out of bed Stress Factor 1.00 1.10 1.15 1.30 1.10 1.30 1 10 1.30 1.10 1 30 1.20 1.40 1.20 1.40 1.20 2.00 Activity Factor 1.2 1.3 Example: Energy requirements for patient with cancer in bed = BEE x 1.10 x 1.2

Metabolic Response to Overfeeding

Hyperglycemia Hypertriglyceridemia Hypercapnia Fatty liver Hypophosphatemia, hypomagnesemia, hypokalemia

ADA: Manual Of Clinical Dietetics. 5th ed. Chicago: American Dietetic Association; 1996 Long CL, et al. JPEN 1979;3:452-456

Barton RG. Nutr Clin Pract 1994;9:127-139

Macronutrients during Stress

Carbohydrate FAT

Macronutrientes during Stress

At least 100 g/day needed to prevent ketosis Carbohydrate intake during stress should be between 30%-40% of total calories Glucose intake should not exceed 5 mg/kg/min

Provide 20%-35% of total calories Maximum recommendation for intravenous lipid p infusion: 1.0 -1.5 g/kg/day Monitor triglyceride level to ensure adequate lipid clearance

Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002; 26 Suppl 1:22SA

Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA

Macronutrients during Stress

Protein

Determining Protein Requirements for Hospitalized Patients

Requirements range from 1.2-2.0 g/kg/day during stress Comprise 20%-30% of total calories during stress

Stress Level Calorie:Nitrogen Ratio Percent Potein / Total Calories Protein / kg Body Weight

No Stress > 150:1 < 15% protein 0.8 g/kg/day

Moderate Stress

Severe Stress < 100:1 > 20% protein

150-100:1 15-20% protein 1.0-1.2 g/kg/day

1.5-2.0 g/kg/day

Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA

Role of Glutamine in Metabolic Stress

Role of Arginine in Metabolic Stress

Considered conditionally essential for critical patients Depleted after trauma Provides fuel for the cells of the immune system and GI tract Helps maintain or restore intestinal mucosal integrity

Provides substrates to immune system Increases nitrogen retention after metabolic stress Improves wound healing in animal models Stimulates secretion of growth hormone and is a precursor for polyamines and nitric oxide Not appropriate for septic or inflammatory patients.

Giving arginine to a septic patient is like putting gasoline on an already burning fire.
Smith RJ, et al. JPEN 1990;14(4 Suppl):94S-99S; Pastores SM, et al. Nutrition 1994;10:385-391 Calder PC. Clin Nutr 1994;13:2-8; Furst P. Eur J Clin Nutr 1994;48:607-616 Standen J, Bihari D. Curr Opin Clin Nutr Metab Care 2000;3:149-157 - B. Mizock, Medical Intensive Care Unit, Cook County Hospital, Chicago, IL Barbul A. JPEN 1986;10:227-238; Barbul A, et al. J Surg Res 1980;29:228-235

Key Vitamins and Minerals

Vitamin A Vitamin C B Vitamins Pyridoxine Zinc Vitamin E Folic Acid, Iron, B12 Wound healing and tissue repair Collagen synthesis, wound healing Metabolism, carbohydrate utilization Essential for protein synthesis Wound healing, immune function, protein synthesis Antioxidant Required for synthesis and replacement of red blood cells

Nutritional Assessment
Medical Physical

history

examination
Biochemical

markers Anthropometric measures

Tools for Nutritional Evaluation

Malnutrition Screening Tool (MST)1 Malnutrition Universal Screening Tool (MUST)2 DETERMINE for screening and assessment3 Subjective Global Assessment (SGA)4

Subjective Global Assessment

Medical History Weight change
9 9

Physical Exam

Loss of subcutaneous fat Muscle wasting Ankle edema Sacral edema Ascites

Past 6 months, 3 months Past 2 weeks

Patient-Generated SGA

(PG-SGA)5

Dietary intake compared t usual to l GI symptoms Functional capacity

9 9 9 9

Mini Nutritional Assessment (MNA)6 Nutritional Risk Index (NRI)7

1. Ferguson M et al. 1999. Nutrition 15:458-464. 2. www.bapen.org.uk/the-must.htm 3. www.aafp.org/Pre-Built/NSI_DETERMINE.pdf 4. Detsky A et al. 1987. JPEN 11:8-13. 5. Ottery FD. 1996. Nutrition 12:S15-S19. 6. Guigoz Y et al. 2002. Clin Geriatr Med 18:737-757. 7. Pablo A et al. 2003. Eur J Clin Nutr 57:824-831.

No dysfunction Working sub-optimally Ambulatory Bedridden

A - Well Nourished B - Moderately (or suspected C - Severely Malnourished

Detsky A et al. 1987. JPEN 11:8-13.

of being) malnourished

Metabolic needs of disease

Nutritional Assessment
Medical Physical

Nutritional Assessment
Medical Physical

history

examination
Biochemical

markers Anthropometric measures

Serum albumin Serum transferrin Serum prealbumin Total T l lymphocyte l h count Serum cholesterol Nitrogen balance

history

examination Biochemical markers Anthropometric measures

Height Weight TSF MAC

Nutrition Risk Assessment Form

BMI

nomogram
<18.5 18.5 18.5 - 25 25 - 30 >30

Underweight Normal Overweight Obese

Evaluation of Weight Change

Nutritional Requirements
Indirect

Time 1 week 1 month th 3 months 6 months

Significant of Weight Loss 1% to 2% 5% 7.5% 10%

Severe Weight Loss > 2% >5% 7.5% 10%

Harris-Benedict
9 Male: M l

Calorimetry formula with Long modification

66 66.47 47 + (13.75 (13 75 x BW) + (5 x h height) i ht) (6.76 x Age) x AF x SF 9 Female: 655.1 + (9.56 x BW) + (1.85 x height) (4.67 x age) x AF x SF

Short * Values charted are for percent weight change: (usual weight - actual weight) x 100 Percent weight change = usual weight

Method
ABW x 25 - 30 kcal/kg IBW x 25 - 30 kcal/kg

9 Underweight: 9 Overweight:

Protein Requirements

Non-Protein Calories
Carbohydrate Fats
9

Non-Stressed

- 0.8 gm/kg/day Mildly y Stressed - 1-1.2 g gm/kg/day g y Severely Stressed - 1.5-2 gm/kg/day Protein should comprise approximately 20% of the total calories during stress

NPC combinations
- acute stress: 70% carbo 30% fat - usual: 60% carbo 40% fat - infections: 50% carbo 50% fat - pulmonary: 40% carbo 60% fat

Vitamin and Mineral Requirements

Nutritional Interventions

Micronutrient,

trace element, vitamin and mineral requirements of metabolically t b li ll stressed t d patients ti t are elevated above normal Give vitamin and mineral requirements daily

Nutritional counseling Oral supplementation Enteral tube-feeding Parenteral feeding

Enteral or Parenteral:
Selecting the Route of Delivery

If the g gut works, use it.

10

Clinical algorithm for N S

The rationale for early EN

Use

of the gut stimulates GALT & MALT resulting in enhanced immune response

Early

feeding can trigger gut immunity and thereby improve outcomes or failure may promote a proinflammatory state with disease severity & morbidity
McClave, J Clin Gastro, Sept 2002

Delay

big

part

Enteral Formulas: Categories

Polymeric Formulas

Polymeric formulas Commercial Blenderized Oligomeric formulas Disease-specific formulas Modular formulas (concentrated protein and carbohydrate preparations)

Contain intact macronutrients and require digestion: I t t proteins Intact t i Polysaccharides Disaccharides Polyunsaturated fatty acids (PUFA) Medium-chain triglycerides (MCT) Vitamins and minerals

small

part

Oligomeric Formulas
Hydrolyzed macronutrients facilitate digestion and absorption Glucose polymers Components Amino acids P l Polyunsaturated t t d fatty f tt acids id

All in One Parenteral Formulas

Optimal utilisation of calories Minimizes metabolic complications - reduced volume load - reduced CO2 production - avoidance of hyperglycaemia - less fat synthesis Permits peripheral administration

Glutamine Arginine
Peptides Monosaccharides Disaccharides
Also

Medium-chain triglycerides Vitamins and minerals

called elemental, semi-elemental,

Rombeauhydrolyzed, JL, Rolandelli RH, eds. Clinical Enteral and Tube Feeding. 3rd ed. formula. WB Saunders Company; 1997 orNutrition: chemically defined

11

Access for Parenteral Nutrition

Take home message (1)

ROUTINE
Assessment

Central PN Peripheral PN Percutaneous Any peripheral vein Subclavian / Jugular Aseptic technique required Femoral at all times PIC line Best removed after 48 72 Cutdown hrs Basilic vein External jugular Aseptic technique required at all times

SCREENING

of risk for nutritionrelated complications index of suspicion

High

Consider

nature of illness and over-all condition of patient in the context of a second insult

Take home message (2)

ACCURATE

Take home message (3)

ROUTE

ASSESSMENT

Accurate Strict

calculation of calorie & protein requirements monitoring of actual feed delivery is more effective than overestimation of patient requirements may be more harmful than underfeeding !

Early

OF DELIVERY & preferential use of EN, combined with PN whenever necessary

MONITORING Pre-op:

IMPLEMENTATION Monitor actual intake as an index of success Post-op: Monitor clinical parameters
DOCUMENT

Overfeeding

THE ENTIRE PROCESS !

What is our measure of success?

Surgical

nutrition will become an established routine in patient care Surgical nutrition will become systematic and organized w/ multidisciplinary participation Patient outcomes will improve The objective proof will be 71 DOCUMENTATION

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