clinical nutrition1/opm germany/stand 02 2003-01-09/1/96 opm. basic care. diabetic care....
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/1/96 OPM
. Basic Care . Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care .
Stoma Care . Wound Care .
B|BRAUNBasics of Nutrition
Clinical Nutrition 1
Basics of nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/2/96 OPM
. Basic Care . Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care .
Stoma Care . Wound Care .
B|BRAUNBasics of Nutrition
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/3/96 OPM
. Basic Care . Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care .
Stoma Care . Wound Care .
B|BRAUNBasics of Nutrition
Significance of Nutrition
health
energy
well-being
body mass
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/4/96 OPM
. Basic Care . Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care .
Stoma Care . Wound Care .
B|BRAUNBasics of Nutrition
Energy Transfer
nutrients O2
NH3 CO2
H2O
chemical energy transfer
osmotic energy transport of substances
chemical energy biosynthesis, reactions
ATP
mechanical energy muscles
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/5/96 OPM
. Basic Care . Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care .
Stoma Care . Wound Care .
B|BRAUNBasics of Nutrition
Energy Units
1 kJoule: quantity of energy needed to move 1 kg 1 m forward by the power of 1 Newton (1 kJ = 0,24 kcal)
1 kcal: quantity of energy needed to warm 1 kg water from
14,5 up to 15,5 °C (1 kcal = 4,186 kJ)
carbohydrates 4 17
fat 9 38protein 4 17
alcohol 7 29
Energy density of nutrients kcal/g kJ/g
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/6/96 OPM
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B|BRAUNBasics of Nutrition
Energy Requirement
basal metabolism = energy required in the state of complete resting
(fasting 12 h) to maintain body functions
activity metabolism = energy required in addition to basal metabolic rate obligat for
musculation digestion and metabolism cellular reactions
total metabolism = basal metabolism + activity metabolism
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/7/96 OPM
. Basic Care . Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care .
Stoma Care . Wound Care .
B|BRAUNBasics of Nutrition
basal metabolic rate (BMR) in kcal according to Harris-Benedict (1919)
f = 655,1 + 9,56 x body weight (kg) + 1,85 x height (cm) - 4,7 x age (years)
m = 66,5 + 13,75 x body weight (kg) + 5 x height (cm) - 6,8 x age (years)p
Determination of Energy Requirement
25 - 35 kcal/kg body weight
female (f), male (m)
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
- little x 1,3- serious (sepsis) x 1,6- burn x 1,5 - 2,0
serious operation x 1,2
cancer x 1,2 - 1,5
bed rest x 1,1
little activity x 1,3
Total Energy Metabolism (in kcal)
total metabolism = basal metabolism x activity factor x illness factor
activity factor illness factor
not in addition to illness factor
for each increased °C + 13 %example: 38 °C x 1,13
39 °C x 1,26
fever infections
according to Long et al. 1979
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/9/96 OPM
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B|BRAUNBasics of Nutrition
• growth
Increased Requirement of Energy
• pregnancy (+ 300 kcal/d)
• lactation period (+ 700 kcal/d)
• convalescence
• loss of energy-rich substances
• stress metabolism
• hormone disorders
• diseases
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/10/96 OPM
. Basic Care . Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care .
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B|BRAUNBasics of Nutrition
Digestion
• desinfection of chyme initiation of digestion of fat and protein dilution of chyme to decrease osmolarity deposition in portions into small intestine (functioning as a reservoir)
mouth
esophagus
stomach
• food intake chewing and insalivation registration of taste initiation of digestion of starch transportation
• transportation esophageal sphincter prevents reflux
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/11/96 OPM
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B|BRAUNBasics of Nutrition
Digestion
• excretion of enzymes into small intestine
- -amylase ( digestion of carbohydrates) - pancreas-lipase ( digestion of fat) - peptidase ( digestion of protein)
• excretion of hormones into blood - insulin - glucagon
pancreas gall bladder
• storage of bile acids
of bile acids into duodenum (emulsification of fats)
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/12/96 OPM
. Basic Care . Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care .
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B|BRAUNBasics of Nutrition
Digestion
• enzymatic decomposition of nutrients
• resorption of nutrients and water
• reabsorption of bile acids
small intestine large intestine
• reabsorption of water
• resorption of electrolytes
• bacterial fermentation of
- not digested carbohydrates and proteins - dietary fibers ( short-chain fatty acids and gases)
- duodenum (0,3 m)- jejunum (1,3 m)- ileum (1,6 m)- ileocecal valve
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/13/96 OPM
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B|BRAUNBasics of Nutrition
Location of Resorption for Different Nutrients
bile
pancreatic enzymes
fatpeptides,amino acidswater magnesiumbile
salts
mono-saccharides
vitamines vitamin B12
stomach
ferrum
colon
calcium
waterelectrolytes,
short-chain fatty acids
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/14/96 OPM
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B|BRAUNBasics of Nutrition
Areas of Resorption of Fats, Proteins and Carbohydratesstomach jejunum ileumduodenum
fat
protein
carbohydrates
resorption in reserve
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/15/96 OPM
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B|BRAUNBasics of Nutrition
Metabolism
•synthesis of fatty acids, ketone bodies, some proteins (for instance albumin, transferrin, acute-phase proteins)
• regulation of amino acid pool in the blood
production of bile acids
storage organ for glycogen, vitamines
detoxification of alcohol, drugs, ammonia
Liver
Blood transport of nutrients, oxygen and decomposition products
• transport of nutrients to organs
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/16/96 OPM
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B|BRAUNBasics of Nutrition
Body Composition1 kg ~ 1,5 % carbohydrates
9 kg ~ 13,8 % fat
11kg ~ 17,0 % protein
40 kg ~ 61,6 % water
4 kg ~ 6,1 % minerals
= 65 kg
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/17/96 OPM
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Stoma Care . Wound Care .
B|BRAUNBasics of Nutrition
• carbohydrates
Nutrients
• fat
• protein
• dietary fibers
• vitamines
• minerals
• trace elements
• phytochemicals
Macronutrients Micronutrients
• water
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/18/96 OPM
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B|BRAUNBasics of Nutrition
• glucose (grape sugar; glc) fructose (fruit sugar; fru) galactose (gal) xylose
Carbohydrates
Monosaccharides = simple sugars
• starch (glc-reserve in plants)• dextrins (fragments of starch)• glycogen (glc-reserve in animals)• dietary fibers
• saccharose (glc-fru) = unrefined sugar maltose (glc-glc) = starch hydrolysate lactose (glc-gal) = milk sugar
Disaccharides = dual sugars
Polysaccharides
sorbitol (alcohol of glucose) xylitol (alcohol of xylose)
Glucose-substitutes
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/19/96 OPM
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B|BRAUNBasics of Nutrition
Digestion of Carbohydrates
organ enzyme reaction
mouth -amylase starch dextrin
maltose
stomach --- --- ---
pancreas -amylase starch dextrin
maltose
small intestine saccharase saccharose glc + fru
maltase maltose glc + glclactase lactose
glc + gal
large intestinebacterial degradation of indigestible carbohydrates
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/20/96 OPM
. Basic Care . Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care .
Stoma Care . Wound Care .
B|BRAUNBasics of Nutrition
• energy substrate 1 g glucose = 4 kcal
Function of Carbohydrates
• energy storage in form of glycogen in liver and muscels
• component of membranes and intercellular substance
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/21/96 OPM
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B|BRAUNBasics of Nutrition
Significance of Glucose
• the only energy source utilized by all body cells
• obligatory fuel for: 1. central nervous system
(supply with energy after long periods of fasting also by ketone bodies)
2. erythrocytes3. renal medulla
4. bone marrow 5. granulation tissue
• daily minimum requirements: ca. 150 g
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/22/96 OPM
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B|BRAUNBasics of Nutrition
Glycemic Index
example: glycemic index of oranges (53 %)
glycemic index = comparison of blood glucose above the fasting value after administrating glucose and after test meal.
25 g glucose = 25 g carbohydrate
280 g oranges = 25 g carbohydrate
time (minutes)
time (minutes)
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/23/96 OPM
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B|BRAUNBasics of Nutrition
Glycemic Index
Substrate specific:
• quantity and quality of dietary fibers
• amount of indigestible starch
• processing of foods
• composition of meal
Subject specific:
• individual metabolism
• individual digestion
• medication (e. g. insulin)
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/24/96 OPM
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B|BRAUNBasics of Nutrition
Digestion of Long-Chain Triglycerides (LCT)
stomach acidic lipase TG 1 FFA (free fatty acid) + diacylglycerol
cholecystis bile acid emulsification of fats
pancreas pancreas-lipases TG 2 FFA + monoacylglycerol
monoacylglycerol 1 FFA + glycerol
small intestine
- intestinal lumen --- resorption of FFA, mono- and diacylglycerol, glycerol
- intestinal cell --- resynthesis to TG in chylomicrons,
release into lymphatic system
organ release of reaction/function
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/25/96 OPM
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B|BRAUNBasics of Nutrition
Cellular Metabolism of Triglycerides
transport
hydrolysis in bloodand in liver
transport liver
transport into mitochondrions
activation by coenzyme A
LCT
as free triglycerides
fast
as triglycerides
MCT
carnitine-dependent transport
lipoprotein-bound
slowly
as remnants ofchylomicrons and VLDL
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/26/96 OPM
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B|BRAUNBasics of Nutrition
Cellular Metabolism of Triglycerides
rate of oxidation
hepatic stress
stress of RES*
tissue-pexis
protein-saving effect
immune system
* reticuloendothelial system
LCT MCT
low
high
high
high
low
high
low
low
low
high
immunological neutralimmuno-modulation
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/27/96 OPM
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B|BRAUNBasics of Nutrition
• fast resorption
Advantages of MCT-Fats compared to LCT-Fats
• direct transport via portal vein into liver
• more efficient oxidation
• immunological neutral
low liver burden
protein-saving effect
maintenance of immune-functions
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/28/96 OPM
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B|BRAUNBasics of Nutrition
• energy substrate (triglycerides) 1 g fat = 9 kcal
Functions of Fats
• energy storage (triglycerides)
• cell structure component of membrane (phospholipids)
• bioactive substances (for instance for prostaglandins)
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/29/96 OPM
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B|BRAUNBasics of Nutrition
Recommendations for Fat Uptake
• 3 fatty acids: maximum of 3 % kcal • relation of 6 to 3 fatty acids: 3 - 5 : 1 • polyunsaturated fatty acids: maximum of 10 % kcal
monounsa-turated
fatty acids
polyunsat-urated
fatty acidssaturated fatty acids
relation of fatty acids
saturated/monounsaturated/ polyunsaturated fatty acids
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/30/96 OPM
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B|BRAUNBasics of Nutrition
Recommendations for Linoleic Acid Uptake
• requirement of linoleic acid ( FA) : 7 - 10 g/day (healthy subjects) in case of serious stress-metabolism requirement may double
• excessive supply of linoleic acid imbalances of the pattern of fatty acids
disorders of immune system
• deficiency of linoleic acid (essential fatty acid deficiency/EFAD) disorders in wound healing skin alterations: xerosis, redness, incrustation thrombocytopenia
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/31/96 OPM
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B|BRAUNBasics of Nutrition
Classes of Fatty Acids
-9
-3
-6
example
example
example
oleic acidC 18:1
linoleic acidC 18:2
-linolenic acidC 18:3
= COOH
= =COOH
= = = COOH
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/32/96 OPM
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B|BRAUNBasics of Nutrition
Protein Structure
smallest unit: amino acid (AA)
20 proteinogenous amino acids
peptide bond between acid- and aminogroup
peptides: chain of amino acids
- dipeptide: 2 AA - oligopeptide: 3 - 10 AA - polypeptide: > 10 AA
globoid structure of amino acid chain by folding
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/33/96 OPM
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B|BRAUNBasics of Nutrition
Proteinogenous Amino Acids
non essential
essential
glycine
alanine
proline
serine
cysteine
tyrosine
asparagine
glutamine
aspartic acid
glutamic acid
arginine
histidine
lysin
threonine
methionine
tryptophan
phenylalanine
isoleucine
leucine
valine
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/34/96 OPM
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B|BRAUNBasics of Nutrition
Digestion of Proteins
stomach denaturation of proteins by acidic milieu pepsin protein
polypeptides oligopeptides
pancreas trypsin polypeptides peptides chymotrypsinpolypeptides peptides
small intestine peptidases peptides amino acids
large intestine bacterial decomposition of not resorbed protein
organ enzyme reaction
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/35/96 OPM
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B|BRAUNBasics of Nutrition
• energy substrate in case of malnutrition 1 g protein = 4 kcal
Functions of Amino Acids and Proteins
• component for synthesis (amino acids)
muscels structure proteins (organs, connective tissue) hormones
transport protein
immunoglobulins (antibodies) enzymes membrane proteins
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/36/96 OPM
. Basic Care . Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care .
Stoma Care . Wound Care .
B|BRAUNBasics of Nutrition
Nitrogen Balance
NBal = Nin - Nout
Nin = N-intake (proteins or amino acids)
Nout = N-excretion through urine + correction for feces + skin
positive N-balance = Nin > Nout
negative N-balance = Nin < Nout(N= chemical symbol for nitrogen)
anabolism
catabolism
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/37/96 OPM
. Basic Care . Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care .
Stoma Care . Wound Care .
B|BRAUNBasics of Nutrition
glucose glycogenesis glycolysisliponeogenesis
glycogenolysis
fat lipogenesis lipolysis
protein protein synthesis proteolysisgluconeogenesis
anabolism catabolism
Metabolic Pathways in Anabolism and Catabolism
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/38/96 OPM
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B|BRAUNBasics of Nutrition
Physiological Significance of Glutamine
• most frequent free intra- and extracellular amino acid
non essential proteinogenous amino acid
nitrogen- and carbon-transport molecule
substrate for gluconeogenesis energy substrate of enteroytes, fibroblasts, lymphocytes
substrate for synthesis of RNA- and DNA-precursors
antioxidative effect (glutathione peroxidase)
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/39/96 OPM
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B|BRAUNBasics of Nutrition
Glutamine in Critical Illness
• release of glutamine from muscels (and lungs), partly from intestinum and kidney.
• energy substrate for immune system, liver and intestinum.
Trauma
Sepsis
• release of glutamine from muscels (and lungs), partly from liver and intestinum.
• energy substrate for cells of immune system and fibroblasts around wound area.
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/40/96 OPM
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B|BRAUNBasics of Nutrition
Water Balance
food 1 L
beverages 1,2 L
oxidation water 300 mL
respiratory air perspiration
urine 1,4 L
feces 150 mL
950 mL
in out
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/41/96 OPM
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B|BRAUNBasics of Nutrition
survival without fluid intake: maximum of 3-4days
Function of Water
• solvent (dilution)
• transport medium
• temperature regulation (perspiration)
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/42/96 OPM
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B|BRAUNBasics of Nutrition
Dietary Fibre
Carbohydrates, which cannot be broken
down by
the enzymes in the human intestinal tract
(indigestible) as well as lignin
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Classification of Dietary fibre
Indigestible polysaccharides
depending on the analyses methods used classified as
- NSP = non-starch polysaccharides
- TDF = total dietary fibre
This definition does not include other indigestible constituents of
food,
which act similar to dietary fibre in the intestine, e.g.:
- Polyalcohols - indigestible proteins
- Polydextroses - indigestible lipids, waxes and fat
replacement substances
- Fructo-oligo-saccharides - Maillard products
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/44/96 OPM
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B|BRAUNBasics of Nutrition
Indigestible Constituents of Food
• are only indigestible for human digestive enzymes
• reach the colon virtually unchanged
• can be fermented by bacterial enzymes
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/45/96 OPM
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B|BRAUNBasics of Nutrition
Dietary Fibre
Insoluble
Lignin
Cellulose
Hemi-cellulose
Resistant starches
Soluble
Gums (gummi arabicum, guar)
ß-Glucanes (oats, barley)
Pectin
Mucous substances
Inulin
Fructo-oligo-saccharides (FOS)
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/46/96 OPM
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B|BRAUNBasics of Nutrition
Dietary FibreCarbohydrates
Indigestiblecarbohydrates(dietary fibre)
Mono-saccharides
+
Poly-saccharide
Di-saccharides
Non-starchpolysaccharides(dietary fibre)
Starch-polysaccharides(Resistant starches)
Indigestibleoligo-saccharides
Soluble insoluble
GP: Degree of polymerisation Dietary fibre with prebiotic effect= prebiotics
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/47/96 OPM
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B|BRAUNBasics of Nutrition
Fermentation of Dietary Fibres by Bacteria in the Colon
Dietary Fibre
LigninCelluloseHemi-cellulose
Pectin
GumsMucous substancesInulinOligo-fructoseResistant starches
• Short-chain fatty acids - Butyric acid (butyrate) - Propionic acid (propionate)- Acetic acid (acetate)
Decomposition Products
• Gases - Carbon dioxide (CO2) - Hydrogen (H2) - Methane (CH4)
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/48/96 OPM
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B|BRAUNBasics of Nutrition
Effects of Dietary Fibres
• Fermentation products: short-chain fatty acids
• Faecal volume -
- Water binding- Biomass/bacteria
Reduction of diarrheas and obstipation
• Gastro-intestinal transit time
• Carcinogenesis by diluting carcinogens and toxins in the faeces
• Blood sugar levels
• Cholesterol
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/49/96 OPM
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B|BRAUNBasics of Nutrition
Long-Term Effects of Dietary Fibres
• Gall stones
• Inflammatory intestinal illnesses
• Ulcus duodeni
• Haemorrhoids
• Irritable intestine
• Colon carcinomas
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/50/96 OPM
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B|BRAUNBasics of Nutrition
Prebiotics
Indigestible constituents of food, which have an effect on the organism (man), which
• selectively and specifically promote the growth and/or the activity of one or a limited number of bacteria in the intestine
• have the potential to improve health
(Gibson & Roberfroid, 1995)
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B|BRAUNBasics of Nutrition
Probiotics
Preparation or product from vital, defined microorganisms
• in an adequate number
• change the microflora in a section of the host‘s body as a result of implantation or colonisation
• exert a favourable effect on the health of the host
(Havenaar & Huis In‘t Veld, 1992; Schrezenmeir & de Vrese, 2001)
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Symbiotics
Mixture of pre- and probiotica, which favourably affect the host
• by implantation of living microorganisms in the
gastrointestinal tract
• by improving the survival of the probiotica
(Gibson & Roberfroid, 1995)
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Intestine: Functional Differences
Small intestine
• Digestive secretions from: stomach, pancreas, bile & intestines
• pH approx. 2 – 6.5
• low bacteria colonisation
• surface enlargement: Kerckring‘s folds, villi, (Lieberkühn‘s crypts), brush border
Colon
• no human digestive secretions
• pH 6 - 7
• high degree of bacteria colonisation
• surface enlargement due to
Lieberkühn‘s crypts, brush border
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/54/96 OPM
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B|BRAUNBasics of Nutrition
Surface ProtectionProbiotic bacteria (e.g. lacto-bacillae)
Phospho-lipids
Surface protection
system
Mucous membrane
Phospho-lipids
Intestinal epithelium cells
Beaker cells
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2003-01-09/55/96 OPM
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B|BRAUNBasics of Nutrition
Intestinal Flora
Totality of all bacteria in the intestines (type and number)
• approx. 10 14 (100,000,000,000,000) cells
• approx. 400 - 500 different species
• influenced by - regions (Europe, Japan, North America, etc.)
- age - nutrition (breast-feeding/ready-made meals,
regions)- diseases- medication (antibiotics, chemo-therapy
drugs)
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/56/96 OPM
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B|BRAUNBasics of Nutrition
Bacterial Fermentation
Breakdown of nutrients by bacterial enzymes
• partial aerobic fermentation in the small intestine
• Anaerobic biosis in the colon (lack of oxygen)-> fermentatie only to intermediate products
(short-chain fatty acids, lactate, gases, etc.)
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Bacterial Colonisation of the Intestine
1
2
3
4
5
Stomach (1) and duodenum (2)(101 - 103 KBE/mL)
LactobacillaeStreptococciYeasts
Jejunum (3) and Ileum (4)(104 - 108 KBE/mL)
LactobacillaeColiformsStreptococciBacteroidsBifidobacteriumFusobacterium
Colon (5)(1010 - 1012 KBE/mL)
Bacteroids Bifido bacteriumStreptococciEubacteriumFusobacteriumColiformsClostridesLactobacillaeProteusStaphylococciPseudomonadesYeastsProtozoa
(KBE=Colony forming units oer ml intestinal content org faeces)
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Fermentation Substrates
Approx. quantity consumed by substrate (g/day)
CarbohydratesResistant starch 8 – 40
Non-starch polysaccharides 8 – 18
Unabsorbed sugar and sugar alcohols2 – 10Oligo-saccharides 2 - 8Chitin and amino sugar 1 - 2Synthetic carbohydrates:Lactulose, lactitol, polydextrose, etc
other indigestible constituents of food
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
FermentationIndigestiblecarbohydrates
- Polysaccharide
- Oligosaccharide
- Monosaccharide
Secretion productsCell constituents
Bacterial hydrolysisof the complex carbohydrates
LactateEthanolSuccinate
Bacterialfermentation
Bacterialbiomass
Short-chain fatty acids - Acetate - Propionate - Butyrate
GasesCarbon dioxideHydrogenMethaneH2S
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Effects Short Chain Fatty Acids
• Energy substrate for colonocytes
• Promotion of mucosal blood circulation
• Anti-diarrhea effect due to coupled absorption with sodium and water
• Mucous secretion of the mucosa = surface protection layer
• Cell proliferation of the intestinal epithelium
• Cell differentiation: mutagenic cells due to butyrate
• Post-operative outcome, colitis
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/61/96 OPM
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B|BRAUNBasics of Nutrition
The Probiotic Concept
Administration of a preparation or a product with probioticbacteria
• Living cultures
• Must remain vital under use and storage
• Must survive the passage through stomach and small intensive (gastric acids, bile, etc.)
• Shall change microflora in a section of the intestines, through implantation or colonisation
• Induce health benefits for the host
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/62/96 OPM
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B|BRAUNBasics of Nutrition
Probiotic Bacteria
Bifido bacteria
• Approx. 25 % of the bacteria population in an adult human, up to 95 % in newborn babies
• Produce vitamins (mostly B-vitamins)
• Saccharolytic bacteria
• Metabolic end products: strong acids, mostly acetate and lactate
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Probiotic Bacteria
Bifido-bacteria: potential health-promoting effects
• pH-value, blocks pathogenic microorganims, promotes acidophilic bacteria
• Secretion of bacteriocines = block pathogenic microorganisms
• Beneficial for intestinal flora during antibiotics therapy
• Act as immune modulators against malign cells & pathogenic microorganisms
• Acidification promotes detoxification of potential toxic substances (e.g. ammonia)
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/64/96 OPM
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B|BRAUNBasics of Nutrition
Probiotic Bacteria
Lacto-bacillae
• Metabolic end products: short-chain fatty acids
• pH-value, blocks pathogenic microorganisms, promotes acidophilic bacteria
• Secretion of bacteriocines = inhibit pathogenic microorganisms
• Removal of potential toxic substances
• Stimulation of the immune system
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/65/96 OPM
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B|BRAUNBasics of Nutrition
“Colonic Food“ - Prebiotics
Carbohydrate Colonic food Prebiotic
Resistant starches Yes (Yes)Non-starch polysaccharides
cell wall polysaccharides Yes No
Hemi-cellulose Yes No
Pectin Yes No
Gums Yes NoIndigestible oligo-saccharides
Fructo-oligo-saccharides Yes Yes
Galacto-oligo-saccharides Yes ?
Soy – oligo-saccharides Yes ?
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Resistant Starches
• Starches, which reach the colon undigested
• 10 % of the starch eaten is resistant starch
• uptake per day: 8 - 40 g
• Different types of resistant starches (RS) - RS1: physically resistant starches
- RS2: granular starch- RS3: retrograded starch
• Digestibility depends on - the structure of the starch (amylose, amylopectin) - the preparation (raw, cooked, cooled, water content)
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Resistant Starches
• bacterial fermentation to short-chain fatty acids, especially butyrate
• energy supply for the colon
• in animal trials- bifidogenic- promotion of lactobacillae
• reduces increase in blood sugar levels
• probably anti-carcinogenic- detoxification of carcinogens e.g. sec. bile
acids
• promoted mineral absorption by RS2
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Prebiotics
Prebiotics (fructo-oligo-saccharides)- Oligo-fructose (GP 2- 20)- Inulin (GP 2-
60)
Potential prebiotics - resistant starch
- Galacto-oligo saccharides (GP 3-6)- Soy oligo-saccharides (GP 3)- Raffinose (GP 3)- Lacto-sucrose (GP 3)- Lactulose (GP 2)
GP = Degree of polymerisation
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Occurrence of Prebiotics
Oligo-fructose and inulin Resistant starches
Bananas MaizeChicory RiceGarlic BarleyLeeks WheatRye Leguminous plantsAsparagus PotatoesTopinambour BananasWheatOnions
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Structure of Prebiotics
Saccharose structure of oligo-fructose and inulin
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B|BRAUNBasics of Nutrition
Definition of Prebiotics
• Verification of indigestibility in the small intestine - treatment with human digestion secretions- patients with terminal ileal stoma
• Verification of the prebiotic effect- in-vitro investigations- in-vivo studies human Oligo-fructose & inulin are bifidogens
• Luminal effects- bacteroides, clostridia, enterobacteria- faecal quantity by approx. 1.5 - 2 g/g OF or
inulin- short-chain fatty acids: energy substrate
colonocytes- pH
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Effects of the Prebiotics
• systemic effects- short-chain fatty acids: acetate, propionate
• luminal effects- mineral absorption (Ca, Mg, Fe)- carcinogenics (elimination, detoxification,
inhibition of carcinogenic bacterial enzymes)
- carcinogenesis due to the effect on cell proliferation
and cell differentiation
• potential systemic effects- improvement of the glucose and lipid
parameters
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/73/96 OPM
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B|BRAUNBasics of Nutrition
Advantages of Pre- vs Probiotics
• No living cultures - manufacture- storage- application
• specific nutrition for probiotic bacteria = selective promotion of the bacteria that have already settled
• Conditions for the implantation or colonisation with probiotica - Settlement only successful under selective conditions - Competition with the existing flora
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/74/96 OPM
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B|BRAUNBasics of Nutrition
Nutricomp Dietary Fibre Concept
Inulin 20 %
Soya dietary fibre30 %
Gum arabicum 20 %
Resistant starch 15 %
Cellulose 8 %
Pectin 7 %
insoluble 41 % soluble 59 %
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Basic Principles for Nutrient Intake
about 2 liters beverages about 30g dietary fibers
55%
30%15%
energy substrate distribution
carbohydrates
proteinfat
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Nutrient Requirement for Children
• high energy requirement per kg body weight dependent on age: 100 - 50 kcal/kg body weight high fluid requirement dependent on age: 140 - 40 ml/kg body weight
protein : fat : carbohydrates8 - 12 : 30 - 40 : 50 - 60
• recommended relation of nutrients (% kcal)
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/77/96 OPM
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B|BRAUNBasics of Nutrition
Nutrient Requirement of Elderly People
steady or increasing requirement of critical nutrients and reduced energy requirement
high nutrient density and low energy intake
critical macronutrients
• protein• water• dietary fibers
critical micronutrients
• vitamines: A, D, E, C, B1, B2, B6, folic acid
• minerals: K, Ca, Mg
• trace elements: Fe, Zn
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Protein / Amino Acids Requirement in Clinical Nutrition
good nutritional status 0,8 - 1,0
renal insufficiency 0,6 - 0,8
dialysis 1,2
hepatic insufficiency 0,5 - 1,2
mild catabolism 1,0 - 1,2
catabolism 1,2 - 1,5
serious catabolism 1,5 - 2,5(sepsis, burn,etc.)
state of metabolism g / kg body weight and day
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Fluid Requirement in Clinical Nutrition
1. - 10. kg 100 mL/kg 1000 mL for 10 kg11. - 20. kg 50 mL/kg 500 mL for further 10 kg21. - 50. kg 20 mL/kg 600 mL for further 30 kgeach further kg 10 mL/kg 200 mL for further 20 kg
total 2300 mL/day
body weight requirement example in case of 70 kg body weight
30 - 40 ml/kg body weight and day
additional requirement of fluid in cases of: • fever • diarrhea, vomiting
• sweating • polyuria
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Determination of Requirements (rough calculation)
activity of the patient
bedfast 25 kcal/kg body weight sedentary 30 kcal/kg body weight mobile 35 kcal/kg body weight
total energy requirement (___ kcal x ___ kg body weight) = ___ kcal/d
Fluidrequirement of the patient
normal 30 mL/kg body weight increased (for instance: sweating) 35 mL/kg body weight high (for instance: sweating + fever) 40 mL/kg body weight
total requirement (___ ml x ___ kg body weight) = ___ mL/d
Energy
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/81/96 OPM
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B|BRAUNBasics of Nutrition
Micronutrients
• vitamines
• minerals
• trace elements
essential nutrients, which have to be
supplied daily in a sufficient dose
• phytochemicals
non essential nutrients with a prophylactic
effect for infections, cancer, cardiovascular diseases
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Vitamines
vit. A retinol vit. D calciferol
vit. E tocopherolvit. K antihemorrhagic factor
vit. C ascorbic acidvit. B1 thiaminevit. B2 riboflavinvit. B6 pyridoxinevit. B12 cobalaminfolic acidbiotinpantothenic acid
niacin
water-soluble vitaminesfat-soluble vitamines
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Metabolic cofactors
Possible deficiency symptoms
• skin alterations (vit. B2, vit. B6, biotin, pantothenic acid)
• neuritis, lactate-acidosis (vit. B1)
• cramps (vit. B6)
Biological Significance of B-Vitamines
• carbohydrates
• fat• protein/amino acids
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
• protective factors
• mineral metabolism (calcium)
• visual function, epithelial protection
• blood coagulation
Biological Significance of Fat-Soluble Vitamines and Vitamin C
antioxidants: vitamines C, E, ß-carotin
vitamin D
vitamin A
vitamin K
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Minerals
• sodium
• potassium
• calcium
• magnesium
• phosphate
• chloride
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B|BRAUNBasics of Nutrition
osmotic function
structural function
metabolic function
signal trransduction
Biological Significance of Minerals
water and acid-base balance (phosphate, sodium, potassium, chloride) regulation of osmotic pressure (sodium, potassium, chloride)
•
construction of bone and dental construction (calcium, phosphate)
energetic metabolism (phosphate) enzyme activation (calcium, magnesium, sulfate) development of hydrochloric acid in stomach (chloride)
nerves, muscels, heart(calcium, magnesium, potassium, sodium,
chloride)
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/87/96 OPM
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B|BRAUNBasics of Nutrition
Trace Elements
• iron
• zinc
• copper
• iodine
• chromium
• fluorine
• manganese
• molybdenum
• selenium
• cobalt
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
catalytic function as a complement of enzymes and other proteins
dental mineralisation (fluorine)
Biological Significance of Trace Elements
wound healing (zinc) immune functions (zinc) hormone functions (iodine) antioxidative function (selenium) oxygen transport (iron) respiration (chromium)
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Phytochemicals polyphenols in cereals, green cabbage, artichokes, berries
sulfides in onions, garlic, asparagus
carotenoids / terpenes in many vegetables and fruits
phytosterols cholesterol-like substances from nuts and vegetable seeds
glucosinolates in cruciferous plants (cabbages, radish, mustard)
flavonoids more than 5000 substances, common in most foods
phytoestrogens in cereals, legumes, especially in soya
saponins lectins protease-inhibitors
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Biological Significance of Phytochemicals
Possible effects A B C D E F G H
I J carotenoids x x xphytosterols x x saponins x x x xglucosinolates x x xpolyphenols x x x x x x x xprotease-inhibitors x x xmonoterpenes x xphytoestrogens x x sulfides x x x x x x x x xlectins xA = anticarcinogen D = antithrombotic G = influence on blood pressureB = antimicrobial E = immunomodulating H = anti-cholesteremicC = antioxidative F = anti-inflammatory I = influence on blood glucose
J = digestive
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Nutrients with Antioxidative Effect
• water-soluble
- ascorbic acid (vitamin C) - cysteine - flavonoids, polyphenols, sulfides
• fat-soluble
- tocopherol (vitamin E) - carotenoids / terpenes - phytoestrogens
not-enzymatic antioxidants
- glutathione peroxidase (Se, Gln)- superoxide dismutase (Cu, Zn)- protease-inhibitors
enzymatic antioxidants
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Antioxidants
• high reactivity because of unpaired electrons low intra- and extracellular concentration short biological half-life period• initiating chain reactions
• cofactors of wound healing
• stimulators of humoral and cellular immune reaction
• prevention of sickness (cancer, cardiovascular diseases)
• scavengers of free radicals
Characteristics of free radicals
Functions of antioxidants
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Influence of free Radicals on Cell Metabolism
lipid peroxidation
lesion of cell membranes
denaturation of proteins
loss or alteration of enzymatic functions
damage of nucleic acids / DNA
mutagens or cytotoxic effects stimulation of virus replication
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Role of Antioxidants in case of Cancer and AIDS
decreasedantioxidants
increased free radicals
- decreased oral nutrient intake - maldigestion/malabsorption- increased losses because of diarrhea and vomiting- lower bioavailability of nutrients because of interactions between nutrients and drugs- radiation- and chemotherapy
- radiation- and chemotherapy - immune reactions
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Monitoring
• body weight (kg)
• height (m)
• body-mass-index (BMI=kg/ m2)
• circumference of hip, waist, upper arm
• skinfold thickness (measure of subcutaneous fat )
• muscular strength
Anthropometry Bioelectric impedance analysis
differentiation of body compartments:
• body fat
• body cell mass
• extracellular mass
• body fluid
Clinical Nutrition1/OPM Germany/Stand 02
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B|BRAUNBasics of Nutrition
Monitoring
• basic disease
• gastrointestinal function
• feces
• temperature
• fluid status
general data: laboratory data:
glucose
albumin (long biological half-live periods)
cholinesterase, retinol-binding protein, transferrin (short biological half-live periods)
triglycerides
urea/creatinine
electrolytes
hepatic enzymes