Nutrition in infections

Aryanti R. Bamahry
FK UMI
2018
 Topic of discussion
• Why is it important?
– Role of nutrition in immune system
– Evidenced of nutrional status and process of
infection
• Clinical applications?
– Mini-nutrional assessment, SGA
– Composition
– Route of administration
– Monitoring
 Importance

Cardiac function Pulmonary function

Intake

Microcirculation environment
FOOD Energy provision
• extracellullar
• intracellular Protein synthesis

Carbohydrates, fats, Renal function

protein, electrolytes,
trace elements,
vitamins, special
substrates Body reserves
Body reserves (malnourished)
(adequate fed)
Griffiths, R. “Specialized nutrition support in the critically ill: For whom and when? Clinical Nutrition: Early Intervention;
Nestle Nutrition Workshop Series
Immune response during Inflammation and infection
Tissue inflammation, Early
SIRS organ failure and death
TNF, IL-1, IL-
6, IL-12, IFN,
Inflammatory balance

IL-3

days weeks

IL-10, IL-4, IL-1ra,

Monocyte HLA-DR
Immunosuppression
suppression
2nd Infections Delayed MOF
CARS and death
Insult Griffiths, R. “Specialized nutrition support in the critically ill: For
(trauma, sepsis) whom and when? Clinical Nutrition: Early Intervention; Nestle
Nutrition Workshop Series
Hypermetabolic Response to Stress—
Cause

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
 Metabolic Response to Stress
• Involves most metabolic pathways
• Accelerated metabolism of lean body mass
• Negative nitrogen balance
• Muscle wasting
 Hypermetabolic Response to
Stress—Pathophysiology

Beberapa jam
sampai
beberapa hari Beberapa hari- Beberapa
12/24/2018 8
(1-2 MF,
Winkler hari) minggu
Malone AM. In : Krause’s Food & nutrition. 2008
minggu
 Ebb Phase
• Immediate—hypovolemia, shock, tissue
hypoxia
• Decreased cardiac output
• Decreased oxygen consumption
• Lowered body temperature
• Insulin levels drop because glucagon is
elevated.
 Flow Phase

• Follows fluid resuscitation and O2 transport

• Increased cardiac output begins
• Increased body temperature
• Increased energy expenditure
• Total body protein catabolism begins
• Marked increase in glucose production, FFAs,
circulating insulin/glucagon/cortisol
 Hypermetabolic Response to Stress—

11
Winkler MF. Malone AM. Medical nutrition therapy for metabolic stress : sepsis, rauma, burns, and surgery. In : Krause’s food and nutrition therapy.
 Hormonal Stress Response

• Aldosterone—corticosteroid that causes

renal sodium retention
• Antidiuretic hormone (ADH)—
stimulates renal tubular water
absorption
• These conserve water and salt to
support circulating blood volume
 Hormonal Stress
Response—cont’d
• ACTH—acts on adrenal cortex to release
cortisol (mobilizes amino acids from
skeletal muscles)
• Catecholamines—epinephrine and
norepinephrine from renal medulla to
stimulate hepatic glycogenolysis, fat
mobilization, gluconeogenesis
Nelms MN. Metabolic stress. In : Nutrition therapy & pathophysio
14
CONSEQUENCES OF MALNUTRITION
• Increased morbidity and mortality
• Prolonged hospital stay
• Impaired tissue function and wound healing
• Defective muscle function, reduced
respiratory and cardiac function
• Immuno-suppression, increased risk of
infection
 Nutritional management of severe sepsis
and septic shock
• Early nutritional support improves wound healing
and ↓the susceptibility of critically ill patients to
infection
• Early enteral nutrition may offer more benefit in
preventing sepsis than parenteral nutrition
• Immune-enhancing nutrients and antioxidants,
including arginine and glutamine
Evidence-based analysis of nutrition support in sepsis. In: Clinical
Trials for the treatment of sepsis, Sibbald, WJ, Vincent, JL (Eds),
Springer Verlag, Berlin, 1995, p. 223.
Nutritional management of severe sepsis
and septic shock
• Such enteral formulas may favorably affect the
resistance of the gut to bacterial translocation
or exert direct effects on the behavior of
intraluminal bacteria
Oral glutamine decreases bacterial translocation and improves survival in
experimental gut-origin sepsis. JPEN J Parenter Enteral Nutr 1995; 19:69
 (Mal)nutrition detection
• Nutritional assessment
– Nutrition screening (within 24 hours)
• Body mass index
– Subjective global assessment or mini-nutritional
assessment
• Weight loss > 10%
• Intake accounting (<70%, chronic)
 (Mal)nutrition detection – whose
responsibility?
• Attending physician
• Dietitian
• Nurse
• Best option – nutrition support team
• Department or section heads – presentors and main
proponents
• Administration – has the biggest role in providing for
both suitable environment and manpower
 Hypermetabolic Response to Stress—
Medical and Nutritional Management

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by
Maion F. Winkler and Ainsley Malone, 2002.
 Nutrient Guidelines: Carbohydrate
• Should provide 60 – 70% calories
• Maximum rate of glucose oxidation =
~5 – 7 mg/kg/min or 7 g/kg/day*
• Blood glucose levels should be monitored and
nutrition regimen and insulin adjusted to
maintain glucose below 150 mg/dl
 Nutrient Guidelines: Fat
• Can be used to provide needed energy and
essential fatty acids
• Should provide 15 – 40% of calories
• Limit to 2.5g/kg/day or possibly 1 g/kg/day
IV*
• Caution with use of fats in stressed &
trauma pts
– There is evidence that high fat feedings caused
immunosuppression
– New formulas focus on omega-3s
 Nutrient Guidelines: Protein
• 1.5 – 2.0 g/kg/day to start; monitor
response
• Nonprotein calorie/gram of nitrogen ratio
for critically ill = 100:1
• Giving exogenous aa’s decreases negative
N balance by supplying liver aa’s for
protein synthesis
 Fluid and Electrolytes
Fluid
• 30-40 mL/kg or
• 1 to 1.5mL/kcal expended

Electrolytes/Vitamins/Trace Elements
• Enteral feedings: begin with RDA/AI values
• PN: use PN dosing guidelines

ASPEN BOD. JPEN 26;23SA, 1992

 How much to give in ICU?
• Schofield equation/Harris Benedict
e.g. for 65 year old woman: BMR = (9.2x weight in
kg) + 687, = requirement in Kcal/24hr
• Add Activity and Stress factors e.g. 10% for
bedbound + 20-60% for sepsis/burns
• For 65kg woman ventilated woman with sepsis:
1670 Kcal = approx 25 Kcal/kg/24hr
• No dietitian? Rough guide: 25 Kcal/kg/day total
energy. Increase to 30 as patient improves
 How much to give?

• 0.2g/Kg/day of Nitrogen (1.25g/kg/day protein)

• 30 – 35ml fluid/kg/24 hours baseline
• Add 2-2.5ml/kg/day of fluid for each degree of
temperature
• Account for excess fluid losses
• Adequate electrolytes, micronutrients, vitamins
• Avoid overfeeding
• Obesity: feed to BMR, add stress factor only if severe
i.e. burns/trauma
 Hypocaloric Feedings Have Been
Recommended in:
• Class III obesity (BMI>40
• Refeeding syndrome
• Severe malnutrition
• Trauma patients following shock
resuscitation
• Hemodynamic instability
• Acute respiratory distress syndrome or
COPD
• MODS, SIRS or sepsis
 REDUCED ENTERAL STIMULATION

DECREASED:
• Peyer’s patch leukotrienes + MAdCAM-1
• T & B cells in Peyer’s patches, Lamina propria &
epithelium
• Reduced secretory IgA and altered cytokines
• Mucosal atrophy
• Altered flora
• Decreased gastric acid
• Bacterial translocation
Bacterial Translocation across Microvilli and
How It Spreads into the Bloodstream
 Enteral
• Preserves intestinal mucosal structure
and function
• More physiological
• Relatively non-invasive
• Reduced risk of infectious complications
cf PN (?)
• Relatively cheap
 Jejunal Feeding
• Insertion
• Surgical jejunostomy: at laparotomy
• May reduce incidence of aspiration
• Sometimes increases dose of EN given
over NG
• Indications
 Parenteral Nutrition
• GI tract not functional
• GI tract cannot be accessed
• Inadequate enteral nutrition <80% 3 days
• Do not delay nutrition in malnourished
• Keep 10ml/hr EN if possible
 Supplemental PN
• Optimize EN first if possible (??)
• Villet: Clin Nutr 24, 2005: Caloric debt a/w
increased LOS, vent days and complications
• Need trial to compare early supplemental PN
and early EN with early EN only
• North America/Europe split over use of PN
• Unanswered questions
 Monitoring Response to MNT in Critical
Care Pts: Blood Glucose
• Hyperglycemia (up to 200-220 mg/dl) in critically ill
patients was once considered acceptable
• Recent studies suggest hyperglycemia is associated
with infection, morbidity, mortality
• New goal is to keep BG as close to normal as
possible. Target: <150 mg/dl
• Use insulin drip and sliding scale; convert to
subcutaneous insulin as possible
• Can use intermediate insulins morning and evening
once feedings are tolerated and stable

Charney P. Glycemic control in the ICU. In Sharpening Your Skills as a

Nutrition Support Dietitian. DNS, 2003, p. 210
 HIV - AIDS

• Individual with HIV :

- Decreased oral intake
- GI affected  malabsorption
- Protein,Energy , lipid metabolism ↑↑↑
 lean body wasting
 PEM  common complication of HIV,
the other complication :
- weiht loss, body cell mass depletion,
decreased skinfold thickness and
mid-arm circumference, decreased
binding capasity & hypoalbuminemia
• The general goals of nutrition
intervention in HIV are to
preserve optimal somatic,
visceral protein status , prevent
nutrient deficiencies or excesses
known to compromiser immune
function, minimize nutrition-
related complication that
interfere with either intake or
absorption of nutrients and
enhance the quality of life
• Nutritional assesment :
- Evaluated diet for adequacy of
nutrient
- Anthropometric measurement
- Laboratory value ( albumine,
transferin, retinol binding protein,
transferin, total iron binding capacity
 Nutritional Intervention
Energy
 Depend on the progression of
the disease and development of
complication
 The Harris and Bennedict 
determine BEE
 Energi requirements increase
13% for every degree Celcius above
normal
 A general range for estimated energy
- 2200-2800 Calori (35-40 Cal/gr BW)
Protein
 Estimated for protein as 1 to 1,2
g/kg body weight> Protein may
need tobe restricted who develop
renal or liver disease
Fat
 Malabsorption as manifest by
diarrhea is suspected, a low fat
may with MCT be useful
Fluid
 Fluid needs are the same as
those of well individuals,except
in the presence of severe
diarrhea, nausea and vomiting
and prolonged fever

Vitamin & mineral

Megadoses of vitamin and mineral
should be avoided
• DIET TYPE :
- Qualitative diet
an eating plan based on the
type of food allowed ( soft,
high fiber, tube feeding )
- Quantitative diet
an eating plan based on the
amount of the food constituent
• AIDS DIET 1
- acut HIV with febris, dysfagia,
dyspneu, diarrhea, coma
- Liquid diet, small portion and
frequent
• AIDS DIET 2
• AIDS DIET 3
 General nutrition and anabolic
support
Macronutrients
Anabolic support
Micronutrients
 Improve body nitrogen, calori
balance during hypermetabolic
states, progressive depletion of
structural protein still continues
 Medical Nutrition Therapy
• Medical Nutrition Therapy Involves
Assessment of nutritional status intake,
lab values, anthropometrics, visual
• Evaluation of food intake
foods, fluids, supplements
• Barriers to nutrition
social, psychological, physical
 Frequency for HIV MNT

1- 2 x year for level 1

Level 1: HIV/AIDS asymptomatic)
2 - 6 x year for levels 2 - 4
Level 2: HIV/AIDS symptomatic but stable
Level 3: HIV/AIDS acute
Level 4: Palliative
 FOOD AND NUTRITION MANAGEMENT

Tujuan Asuhan Gizi :

• Mempertahankan kesehatan dan status gizi dari ODHA
• Meningkatkan kekebalan tubuh dari ODHA
• Memperlambat progress HIV + AIDS
• Meningkatkan ‘Quality of life’ dari ODHA
3 aktivitas dari asuhan gizi

Terdiri dari tiga kegiatan :

1) Pemantauan status gizi & makanan
2) Intervensi gizi & makanan
3) Konseling gizi & makanan
 I. Pemantauan status gizi dan
makanan ODHA
Tujuan :
1. Mengetahui status zat gizi makro dan zat gizi mikro
ODHA
2. Mengetahui efek dari infeksi HIV pada status gizi
dan kesehatan ODHA

Cara :
- Anamnesis diet
- Pengukuran antropometri
- Pemeriksaan laboratorium
Metode penilaian status gizi dan makanan (1)

a. Anamnesa Diet :
- Dietary recall selama 48-72 jam
- Konsumsi makanan dan intake zat-zat gizi
- Potensi terjadinya defisiensi zat gizi
b. Assessment dari anthropometry klinik :
- Pengukuran BB dan TB
- Body Mass Index (IMT)
- Protein Energy Malnutrition
- Hanya status zat gizi makro
Metode penilaian status gizi dan makanan (2)

c. Pemeriksaan klinik
- Deteksi kelainan fungsi
- Menemukan tanda mayor dan minor
- Defisiensi zat gizi makro dan mikro
d. Pemeriksaan laboratorium
- hemoglobin, albumin & globulin, kolesterol ,
triglyserida
- Fungsi hati
- Micronutrients serum: serum Iron, vitamin A, dll
 II. Intervensi Gizi dan Makanan
• Dapat memenuhi kebutuhan zat gizi makro
- Asupan makanan adekuat protein, lemak& karbohidrat
- Mempertahankan status gizi ODHA
- Meningkatkan BB
- Mencegah penurunan BB yang drastis
<20%--FATAL
• Dapat memenuhi kebutuhan gizi mikro
- Vit A, B-caroten, C, E, B1, B6, B12
- Zn, Se, Fe, H2obuild up immune bodies, antioksidan, agen
neurotropik
• Food hygiene and safety, food radiation, food
alterationimportant to secure foor for ODHA
 INTERVENSI MAKANAN BERDASARKAN MAKANAN YANG
TERSEDIA DI INDONESIA

• Tempe
- Tinggi protein dan vit. B12
- Bactericidedapat obati dan cegah diare

• Kelapa
- Mengandung medium chains tryglicerides
- Sumber energi yang efektif untuk meningkatkan
pembentukan sel T4
- Mudah diserap dan “NO diarrhoea effect’
 DEVELOPMENT OF FOOD INTERVENTION BASE ON INDONESIAN FOOR FOR ODHA

Wortel
- Tinggi kandungan B-carotentingkatkan immune bodies dengan
tingkat CD4+
- Bersama dengan vitamin E, Cantioksidan (menangkal radikal
bebas)

Brokoli & kembang kol

- Tinggi kandungan mineral : ZN, Mn, Fe, Se
- Mencegah defisiensi spesifik
- Berfungsi sebagai antioksidan
- Pembentuk CD4+
 DEVELOPMENT OF FOOD INTERVENTION BASE ON
INDONESIAN FOOR FOR ODHA

Sayuran hijau dan kacang kacangan

- Mengandung vitamin B dan trace elements
- Tinggi kalsium
- Meningkatkan CD4+

Alpukat
- Kandungan lemak (60%) tertinggi dari buah
- 16% MUFA (Mono-Unsaturated Fatty Acid)sumber energi terbaik
- Konsentrasi Gluthation tertinggi sebagai antioksidanstop replikasi
HIV
 KEBUTUHAN ZAT GIZI MAKRO
• Pada umumnya, konsumsi ODHA dibawah optimal
requirementkalori 70% dan protein 65%

• Adanya infeksi akutmeningkatkan proses metabolisme

• Pemenuhan zat gizi makromencegah penurunan BB

secara DRASTIS
 KEBUTUHAN ZAT GIZI MAKRO
• Kebutuhan KALORI : 2000-3000 kal/hari

• Kebutuhan PROTEIN: 1, 5-2 gr/kg BB/hari

• LEMAK 10-15% dari total kalori/hari

- Berasal dari MCT  absorbsi lebih baik

 mencegah diare
- Baik karena tinggi protein, rendah lemak
 KEBUTUHAN ZAT GIZI MIKRO
• Virus HIV merusak sel imun tubuh
• Cegah terjadinya defisiensimempercapat
progressAIDSkarena kegagalam metabolisme
• Pemberian suplementasiTIDAK kembali ke
NORMALsindrom Baloon
• Suplementasi megadosis dapat menekan imunitas
• Membentuk sel imun baru Diperlukan vit A, B-karoten, C dan E,
Se, Fe, Cu, Vit. B1, B6, B12
• Diperlukan 2-5 kali RDA
• Kebutuhan H20 penting untuk ‘body restore’
 INTERVENSI GIZI
Tujuan : mempertahan status gizi agar ODHA tidak
cepat masuk tahap AIDS

• Harus dilakukan secara komprehensif meliputi upaya promotif,

preventif, kuratif dan rehabilitatif
• Meningkatkan energi dan/atau protein yang dibutuhkan (penting
mengobati penyakit yagn ada)
• Meningkatkan kalori sebesar 159% dari kebutuhan normal
• Dapat dilakukan di RS, pelayanan kesehatan lain dan keluarga
• Di RS idlakukan oleh tim asuhan gizi
Syarat diet pada orang dengan HIV

• Zat gizi dihitung sesuai kebutuhan individu

• Konsumsi protein berkualitas
• Banyak sayuran dan buah buahan (kaya vit. Dan
mineral)
• Minum susu tiap hari
• Hindari makan diawetkan dan beragi
• Makanan bebas pestisida dan bahan kimia
• Hindari rokok, kafein dan alkohol
 SYARAT DIET PADA PASIEN AIDS (1)

• Kebutuhan zat gizi ditambah 10-25% dari kebutuhan

minimum
• Diberikan dalam porsi kecil tapi sering
• Konsumsi protein berkualitas tinggi dan mudah
dicerna
• Sayuran dan buah buahan dalam bentuk jus
• Susu rendah lemak dan sudah dipasteurisasi, setiap
hari (susu sapi atau kedelai)
 SYARAT DIET PADA PASIEN AIDS (2)

• Hindari makanan diawetkan atau beragi

• Bebas dari pestisida ataubahan kimia
• Rendah serat, makanan lunak/cair, jika ada
gangguan sal.pencernaan
• Rendah laktosa dan lemak jika diare
• Hindari rokok, kafein, alkohol
 3. KONSELING GIZI
Tujuan :
ODHA mendapat jaminan kebutuhan gizi sesuai kondisi kesehatan
dan kemampuan keluarga, pendamping ODHA dan masyarakat

Konseling meliputi:
- Penyuluhan HIV/AIDS
- Pengaruh infeksi HIV pada status gizi
- Tatalaksana gizi, terapi gizi medis, penyusunan diet, pemilihan
bahan makanan, aspek psikologis, efek samping ARV-I.O. yang
mempengaruhi nafsu makan, dll.
 Gejala klinis dan keterkaitan dengan
gangguan gizi (1)
• Anoreksia & disfagia
- Obat ARV penurunan nafsu makan
- Infeksi jamur pada mulut sulit menelan
Hal ini memerlukan terapi diet lunak, makanan tidak
merangsang, makanan dingin, minum melalui sedotan Khusus

• Diare akut/malabsorbsi
- Hilangnya zat gizi seperti vitamin & mineral
Perlu cairan, buah buahan rendah serat, tinggi kalium &
magnesium
Hindari makanan berlemak dan jus berlebihan
 Gejala klinis dan keterkaitan dengan
gangguan gizi (2)
• Sesak nafas
- makanan tinggi lemak rendah KHmengurangi CO2
- Porsi kecil tapi sering

• Gangguan penyerapan lemak

- Diet rendah nabati
- Konsumsi minyak nabati (minyak kedelai, minyak jagung, minyak
sawit)
- Tambahan vit. A,D,E, K.
 Gejala klinis dan keterkaitan dengan
gangguan gizi (3)
• Demam
- Kebutuhan protein meningkat
- Makanan lunak porsi kecil, jumlah lebih dari biasa
- Minum lebih dari 2 liter/8 gelas sehari
• Penurunan BB
- Dicari penyebabnya
- Pastikan apa ada infeksi opurtunistik
- Makanan TKTP porsi kecil sering, rendah serat
 KEAMANAN MAKANAN DAN MINUMAN

Mengurangi kontaminasi bahan makanan

dan minuman yang risiko keracunan atau
tertular infeksi, perlu diperhatikan:
- Tidak makan makanan kaleng kadaluarsa
- Hindari daging, ikan, & telur mentah, daging ayam
termasuk unggas setengah matang.
- Hindari konsumsi sayur mentah/lalapan
- Sedapat mungkin hindari jajan
 RANGKUMAN
• Kompetisi antara pengrusakan oleh HIV dan pembentukan sel baru
dari gizi STATUS ODHA
• Supplementasi gizi dan makanan penting dalam peningkatan sataus
gizi dan kesehatan ODHA
• Suplementasi gizi dan makanan mencegah ODHA jatuh ke dalam
defisiensi
• Pentingnya meningkatkan kualitas hidup ODHA
• Segera dilakukan penilaian status gizi dan dietary intake pada saat
pasien datang pertama kali
• Intervensi dan konseling gizi direncanankan dalam ASUHAN GIZI
selanjutnya sesuai dengan klinis
 DEMAM TIFOID
A. Konvensional
Mulai bubur saring :
- menurunkan beban kerja
usus
- menurunkan perdarahan
- Netralisasi asam lambung
Syarat bubur saring :
- Mudah dicerna, porsi kecil tapi
sering
- Protein cukup
- memenuhi kebutuhan normal
- kurang bumbu yang tajam
Makanan padat, rendah serat
- defekasi  bulk forming
- BB naik
- Jumlah kalori segera
terpenuhi
- dipersiapkan lebih mudah
- meningkatkan selera makan
 diet yang dipakai sekarang
DIET ENERGI TINGGI PROTEIN
TINGGI
Diet yang mengandung energi dan
protein diatas kebutuhan normal
Tujuan diet :
- Memenuhi kebutuhan energi
dan protein untuk mencegah
kerusakan tubuh
- Menambah BB hingga mencapai BB
normal
Syarat diet ETPT :
- Energi 40-45 kkql/kg BB
- Protein 2-2,5 g/kgBB
- Lemak 10-20% dari kebutuhan energi
tot.
- Karbohidrat, vitamin , mineral cukup
Jenis diet :
- Diet ETPT I
- Diet ETPT II
 SUMMARY
Specialized nutrient needs of the INFECTION
patient:
– Increased calories to cover energy costs of
hypermetabolic
– High fat diets.
– Adequate protein levels to support anabolism and
the maintenance of lean body mass..
– Supplemental antioxidants to prevent or attenuate
oxidative damage to tissue
 Take Home Message !
• Terapi nutrisi harus menjadi bagian dalam
tatalaksana menyeluruh kasus infeksi
• Assesment status nutrisi harus dilakukan
seiring dengan tatalaksana terapi definitif
• Penting untuk menentukan fase
metabolisme dari pasien untuk dapat
memberikan asupan energi, protein, dan
lemak yang tepat