FCM 60 to 70%

Dr. Praire 2. Thermogenic effect of digestion

Clinical Nutrition 10%
3. Physical activity
Basic Principles: 5 to 30%
The consumption of energy is vital to sustain life 4. Illness/ metabolic stress
The foundation of clinical nutrition is to With the exception of burns
o Preserve lean body mass <50%
o Maintain immune function 5. Growth
Variable
Energy: Overview of Energy Metabolism
Basic fuels of the body Methods to Determine Energy Expenditure
o Carbohydrates Unit in kilocalories (kcals)
o Fats kcals- the amount of heat required to rise 1 kilojoule (kj) of water
o Proteins 1C

Carbohydrates Measurement of Energy Expenditure

Major energy source in human nutrition Direct calorimetry
Providing approximately 45% to 65% of our daily energy o Measures heat released from the subject
Theoretically, oxidation of 1 gm of carbohydrate yields 3.9 kcals o The subject resides within the chamber
of energy o Not practical and uses healthy subjects
Can be stored in the body as glycogen mainly in the liver and Indirect calorimetry
muscles for later use o gold standard
Can be used as sweetening agents o Most accurate in determining energy expenditure in
Components of dietary fibers, important in fermentation process critically ill patients
o Indicated in patients who fail to respond to nutrition
Fats support based on predictive equations
Used to provide energy and essential fatty acids o It measures both REE (RMR) and Respiratory Quotient
Sources: soybean oils, safflower oils, sunflower oils, canola oils, (RQ)
olive oils, etc.
LCT- cal value of 9 kcal/g
Substrate utilization RQ
MCT- cal value of 8.3 kcal/g Ethanol 0.67
Omega 3 FA- 3 to 5 g/day Fat oxidation 0.71
Protein oxidation 0.82
MCT and LCT Mixtures Mixed substrate oxidation 0.85
Mixtures in MCTs and LCTs (50:50 wt:wt mixture) in PN is limited Carbohydrate oxidation 1.0
Lipogenesis 1-1.2
Advantages
o Providing a better oxidized energy source
Interpretation of RQ
o Improving nitrogen balance
RQ= Vco2/Vo2
o Proving rapid clearance from the blood
o Shown to produce FA profile (from cellular
Calculation Methods Using kcal/kg
phospholipids) that is closer to normality when
A.S.P.E.N Guidelines
compared to individuals who receive LCT emulsions
o 20 to 35 kcals/kg/day
alone.
o Generally adequate = 25 kcals/kg/day
o Note for Refeeding Syndrome
Proteins
Start at 20 kcals/day
Crystalline amino acids (in IV form) and plain amino acids (in oral

and enteral form)
Calculation Methods to Determine Energy Expenditure
Standard or balance amino acid products are mixtures of
Harris- Benedict Equation
essential and non- essential amino acids
Men: energy expenditure= 66 + 13.75 (wt in kg) + 5 (ht in cm) -
Major glucose precursor (in gluconeogenesis)
6.8 (age)
Glutamine
Women: energy expenditure= 655 + 9.6 (wt in kg) + 1.8 (ht in cm)
o Conditionally essential AA
4.7 (age)
o Crystalline AA does not contain glutamine
Limitations
o 0.2 to 0.5 g/kg/ABW/day
o They do not represent body weight and height, age or
Arginine
racial diversity of the current generations because the
o Important in wound healing and immune function
data were collected nearly a century ago.
Branched Chain Amino Acids (BCAA)
o Valine, leucine, and isoleucine
Non- Protein Calories (NPC)
o Can be significantly decreased in cirrhosis
The portion of TCR or TEE which is the non- protein part namely
o May only be effective for patients with advanced
carbohydrates and fats.
cirrhosis who are intolerant to alimentary problems
Why need for NPC?
Aromatic AA
The answer lies in the protein requirements of the body
o Phenylalanine, tyrosine and tryptophan
To achieve protein build- up or positive metabolic status you
need energy and this is where your NPC comes in.
Components of Energy Expenditure
Protein sparers
1. Basal or resting metabolic rate
 Fatty Foods
Fatty food- 1 serving= 5 gms= 45 kcals
Saturated foods
o Bacon=10 gms= 1 strip (10x3 cms)
o Butter, coconut oil, margarine, mayonnaise, coconut
cream, cream cheese, sandwich spread, whipping
cream= 15 gms= 1 tsp
o Sitsaron= 10 gms= 2 pcs= 5x3 cms each
Polyunsaturated
o Oil (corn, soybean, safflower, sesame, rape-seed
canola, sunflower)= 5 gms= 1 tsp
Monounsaturated
o Avocado= 65 gms= of 12x7 cms
o Peanut, olive oil
o Butong pakwan= 10 gms= 1 tsp

Meat and Meat Products

Lean Meat
o Lean meat (beef, carabeef, chicken)
o Lean pork
o Chicken leg
o Chicken breast
o Liver, blood, gizzard, heart, lungs, small intestines,
spleen
o Fish
The USDA Food Pyramid o Alamang
o Alimasag, alimango meat (crab)
o Lobster
o Shrimps
The USDA Food Plate o Prawns
o Squid

Medium Fat Meat

o Beef (flank, brisket plate, chuck)
o Pork, pata (leg)
o Brain (beef, prok, carabeef)
o Fish
o Chicken egg
o Quails egg
o Cheddar cheese
o Soybean
o Sardines, canned in c/tomato sauce
o Tuna sardines
o Tofu
o Tokwa
o Corned beef
Lean meat
o Halaan (clam)
o Kuhol (snail)
The USDA Food Eating Plate o Monggo
o Dried fish (daing)
o Fishball
o Tinapa, bangus
o Tuyo: sapsap, tunsoy
o Dried pusit
o Salmon, canned
o Tuna in brine/water
o Tocino lean without sugar

Meat Carbohyda Protein Fats Calories

te
Lean meat= 30 gms= 1 * 8 1 41
slice/ 1 mbs= 5x3.5x1.5
cms

Medium fat meat

* 8 6 86
High fat meat
* 8 10 122
Milk and Milk Products Too much insoluble fiber can cause gastrointestinal problems
such as bloating, flatulence, and increased frequency of bowel
Milk Carbohydr Protein Fats Calories
movements
ates
Whole milk 12 8 10 170

Low fat 12 8 5 125 Significant Weight Loss

Skimmed milk % Weight loss= usual body weight- actual weight

X 100
Very low fat 12 8 80
Usual body weight
milk

Interpretation:
Vegetables Significant weight loss
1 serving= 3 gms of carbohydrates, 1 gm protein, 16 calories 5%- over 1 month
7.5%- over 3 months
Leafy vegetables= 1 cup= 25 gms= raw; cup= 45 gms= cookes
10%- over 6 months
Non- leafy vegetables= cup= 40 gms= raw; cup= 45 gms=
cooked
Severe weight loss
o Fresh
>5%- over 1 month
o Processed
>7.5%- over 3 months
>10%- over 6 months
Rice
1 serving= 23 gms carbohydrate, 2 gms protein, 100 calories
Limitations of Screening Test
o Rice= 80 gms= cup
These tests are not intended to be fully diagnostic. Positive
o Pan de sal= 40 gms= 2 pcs (7x4 cms)
responders require further investigation.
o Skyflakes= 35 gms = 4 pcs
These tests do not give a lifetime guarantee that the person will
o Crackers= 35 gms= 8 pcs (5x4 cms)
never develop the disease of interest. Repeated tests are
o Oatmeal cooked= 185 gms= 1 cup, thick consistency
necessary.
o Popcorn, plain= 35 gms= 2 cups

Benefits and Harms

Computing for Degree of Obesity
Benefits Harms
Earlier detection and Cost
BMI Value appropriate intervention Side- effects
Normal 18.5-25 result in a better o Physical
Overweight 26-30 outcome o Psychological
Obese I 31-35
Obese II 36-40
BMI Interpretation Secondary Level of Prevention

WHO/ ASPEN Asia Pacific Moderate Physical Activity Approximate Calories/30 Approximate
<18.5- underweight <18.5- underweight minutes for a 154 lb person calories/ hr for
18.5-24.9- normal 18.5-22.9- normal a 154 lb person
25-29.9- overweight 23-24.9- at risk Hiking 185 370
>=30- obese 25-29.9- obese I Light gardening/ yard work 165 330
30-34.9- obese I >=30- obese II Dancing 165 330
35-39.9- obese II
Golf (walking and carrying clubs) 165 330
>=40- obese III
17-18.4- PEM grade I Bicycling (<10 mph) 145 290
16-16.9- PEM grade II Walking (3.5 mph) 140 280
<16- PEM grade III Weight lifting (general light 110 220
workout)
Soluble Dietary Fiber Stretching 90 180
Soluble fiber sources include oats, legumes, pectin, psyllium, and Case Finding
certain gums o Presence/ occurrence of the disease
Recent studies indicate that adding some forms of soluble fiber o Occurrence of the disease in the patient per se or
to a diet reduced in fat and cholesterol can result in an additional other member of the family
decrease in serum cholesterol o Identification of the disease if its lifestyle, work
Two possible mechanisms for the effect of soluble fiber on serum related or familial related
cholesterol metabolism: o Plan/ recommendation
o Soluble fiber may alter the site of absorption in the
gut resulting in a change in the composition of Physical Activity/ Exercise
chylomicrons Calories used per Hour in Common Physical Activities

Insoluble Fiber
Adds bulk to stools and promotes normal colonic function
Wheat bran cellulose does not lower serum cholesterol levels,
although I may have other health benefits
 Vigorous Physical Activity Approximate Approximate
Calories/30 calories/ hr for a 154
minutes for a 154 lb person
lb person
Running/ jogging (5 mph) 296 590
Bicycling (>10 mph) 296 590
Swimming (sow freestyle 255 510
laps) 240 480
Aerobics 230 460
Walking (4.5 mph) 220 440
Heavy yard work (chopping 220 440
wood) 220 440
Weight lifting (vigorous
effort)
Basketball (vigorous)

Lifestyle Modification to Manage Hypertension

Modification Recommendation Approximate Systolic BP Reduction

Range
Weight reduction Maintain normal body weight (BMI 18.5- 24.9) 5-20 mmHg/ 10 kg weight loss

Consume a diet rich foods, vegetable and low fat

Adopt DASH eating plan dairy products with a reduced content of saturated 8-14 mmHg
and total fat

Reduce dietary sodium intake not more than 100

Dietary sodium reduction
Physical activity
Moderation of alcohol
reduction
mEq/L, (2.4 g sodium or 6 g sodium chloride)
2-8 mmHg
Engage in regular aerobic physical activity such as
brisk walking (at least 30 mins per day, most days of
the week)
4-9 mmHg
Limit consumption not more than 2 drinks per day [1
oz or 30 ml ethanol (e.g. 24 oz beer, 10 oz wine, or 3
oz 80- proof whiskey)] in most men and no more
than 1 drink per day in women and lighter- weight
persons 2-4 mmHg