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The Malnourished Patient: Nutritional Assessment And

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The Malnourished Patient: Nutritional Assessment And THE MALNOURISHED PATIENT : NUTRITIONAL ASSESSMENT AND MANAGEMENT Samuel Klein and Khursheed N. Jeejeebhoy BASIC NUTRITIONAL CONCEPTS, 265 MALNUTRITION, 271 Refeeding Syndrome, 277 Energy Stores, 265 Specific Nutrient Deficiencies, 271 Clinical Recommendations, 278 Energy Metabolism, 265 Protein-Energy Malnutrition, 272 PATIENTS WITH SEVERE MALABSORP- Protein, 266 Effect of Protein-Energy Malnutrition on TION, 279 Carbohydrate, 268 Tissue Mass and Function, 273 Clinical Considerations, 279 Lipids, 268 Nutritional Assessment Techniques, 274 Treatment, 280 Major Minerals, 268 REFEEDING THE MALNOURISHED PA- TIENT, 277 Micronutrients, 268 STARVATION, 271 Ingestion and absorption of a nutritionally adequate diet is Energy Metabolism necessary to maintain normal body composition and func- tion. Gastrointestinal (GI) diseases can cause malnutrition by Energy is continuously required for normal organ function, affecting nutrient intake, nutrient absorption, or nutrient re- maintenance of metabolic homeostasis, heat production, and quirements . Therefore, it is important for gastroenterologists performance of mechanical work. Total daily energy expend- to understand the principles involved in evaluating and treat- iture (TEE) is composed of resting energy expenditure (nor- ing malnourished patients . mally -70% of TEE), thermic effect of feeding (normally -10% of TEE), and energy expenditure of physical activity (normally -20% of TEE) . BASIC NUTRITIONAL CONCEPTS Resting Energy Expenditure Energy Stores Resting energy expenditure (REE) represents postabsorptive Endogenous energy stores are continuously oxidized for fuel . energy expenditure while a person lies quietly awake . Dur- Triglyceride present in adipose tissue is the major fuel re- ing these conditions, approximately I kcal/kg body weight is serve in the body and is critical for survival during periods consumed per hour in healthy adults . The energy require- of starvation (Table 15-1) . The high energy density and ments of specific tissues differ dramatically (Table 15-2) . hydrophobic nature of triglycerides make it a fivefold better The liver, gut, brain, kidneys, and heart constitute approxi- fuel per unit mass than glycogen . Triglycerides liberate 9 .3 mately 10% of total body weight but account for approxi- kcal/g when oxidized and are compactly stored as an oil mately 75% of the REE . In contrast, resting skeletal muscle inside the fat cell, accounting for 85% of adipocyte weight . consumes approximately 20% of REE but represents approx- In comparison, glycogen produces only 4 .1 kcal/g on oxida- imately 40% of body weight, and adipose tissue consumes tion and is stored intracellularly as a gel, containing approxi- less than 5% of REE but usually accounts for more than mately 2 g of water for every gram of glycogen . Adipose 20% of body weight . tissue is unable to provide fuel for certain tissues, such as Several equations have been generated to estimate resting bone marrow, erythrocytes, leukocytes, renal medulla, eye energy requirements 2-5 (Table 15-3). The equations for tissues, and peripheral nerves, which cannot oxidize lipids healthy subjects generate values that are usually within 10% and require glucose for their energy supply . During endur- of measured values . However, these equations are much less ance exercise, glycogen and triglycerides present within accurate in persons who are at extremes in weight (either muscle tissue provide an important source of fuel for work- very lean or obese) or who are ill because alterations in ing muscles .' body composition and metabolic stress influence energy ex- 265 pir TIt fR t OGY Table 15-1 1 Endogenous Fuel Stores in a Man Weighing followed by carbohydrate and then fat . A meal containing all 70 kg these nutrients usually increases metabolic rate by 5% to 10% of ingested or infused calories . MASS TISSUE FUEL SOURCE Grams Kilocalories Recommended Energy Intake in Adipose Triglyceride 13,000 120,000 os i l z d t e s Liver Glycogen 100 400 Protein 300 1200 We developed a simple method for estimating total daily Triglyceride 50 450 energy requirements in hospitalized patients based on body Protein 6000 24,000 Muscle mass index (BMI)A (Table 15-6) . In general, energy given Glycogen 400 1600 Triglyceride 250 2250 per kilogram body weight is inversely related to BMI . Blood Glucose 3 12 Triglyceride 4 35 Free fatty acids 0 .5 5 Protein Proteins are composed of amino acids, which are nitrogen- penditure. Malnutrition and hypocaloric feeding decrease containing compounds . Twenty different amino acids are REE to values 15% to 20% below those expected for actual commonly found in human proteins . Some amino acids (his- body size, whereas metabolic stress, such as inflammatory tidine, isoleucine, leucine, lysine, methionine, phenylalanine, diseases or trauma, often increases energy requirements . threonine, tryptophan, valine, and possibly arginine) are con- However, it is rare for most illnesses to increase REE by sidered essential because their carbon skeletons cannot be more than 50% of pre-illness values . For example, patients synthesized by the body. Other amino acids (glycine, ala- with Crohn's disease who do not have an infectious compli- nine, serine, cysteine, cystine, tyrosine, glutamine, glutamic cation have normal metabolic rates6 whereas patients with acid, asparagine, and aspartic acid) are nonessential because severe bums may have a 40% increase in REE.7 they can be made from endogenous precursors or essential amino acids . In disease states, nonessential amino acids may become essential . For example, it has been shown that cyste- Energy Expenditure of Physical Activity ine is essential in patients with cirrhosis 9 because the trans- sulfuration pathway is impaired in these patients . The effect of physical activity on energy expenditure de- The body of an average 75-kg male contains approxi- pends on the intensity and duration of daily activities . mately 12 kg of protein and 2 kg of nitrogen . In contrast to Highly trained athletes can increase their TEE 10- to 20-fold fat and carbohydrate, there is no storage depot for protein, during athletic events. The activity factors shown in Table so excess intake is catabolized and the nitrogen component 15-4, expressed as a multiple of REE, can be used to is excreted . Inadequate protein intake causes net nitrogen estimate TEE in active patients . The energy expended during losses, initially from organs such as the liver and then from physical activity is equal to : muscle mass . Data from nitrogen balance studies suggest that the mean daily protein requirement for adults is 0 .6 g/kg (REE) X (activity factor) (with a standard deviation of 12 .5%). Therefore, a protein X (duration of activity in hours/24 h) . intake of 0 .75 g/kg would meet the requirements of 97% of TEE represents the summation of energy expended during the adult population. However, this amount is based on stud- ies in which a reference protein containing a large propor- all daily activities, including rest periods (Table 15-5) . tion of essential amino acids was used. Requirements for dietary protein of lesser biologic value may be higher . Intra- Thermic Effect of Feeding venously administered amino acids are as effective in main- taining nitrogen balance as oral protein of the same amino Eating or infusing nutrients increases metabolic rate . Dietary acid composition . 1 ° protein causes the greatest stimulation of metabolic rate, Individual protein requirements are affected by several Table 15-2 1 Resting Energy Requirements of a Man Weighing 70 kg TISSUE MASS ENERGY CONSUMED Percentage Kilocalories/gram Percentage TISSUE Grams Body Weight of Tissue per Day Kilocalories/Day REE Liver 1550 2 .2 0.28 445 19 Gut 2000 3 .0 0.15 300 13 Brain 1400 2 .0 0.30 420 18 Kidneys 300 0.4 1 .27 360 15 Heart 300 0.4 0.80 235 10 Skeletal muscle 28,000 40 .0 0.014 400 18 Adipose 15,000 21 .0 0.005 80 4 REE, resting energy expenditure . THr .1AI vi x R+'I+LP PATttN I . W4ty lru t ?t tt, Table 15-3 1 Commonly Used Formulas for Calculating Table 15-5 1 Daily Energy Requirements in Humans Resting Metabolic Rate REE ACTIVITY TEE HARRIS-BENEDICT EQUATION AGE (Yr) (kcal/kg) FACTOR (kcal/kg) Men : 66+(13 .7X W)+(5 X H)-(6 .8XA) Male Women : 11-14 32 .0 1 .70 55 665+(9 .6X W)+(1 .8x H)-(4 .7xA) 15-18 26 .7 1 .67 45 WORLD HEALTH ORGANIZATION 19-25 24 .7 1 .67 40 25-50 22 .8 1 .60 37 Age (Years) Male Female 19 .8 1 .50 30 0-3 (60 .9 X W) - 54 (61 .0X W) - 51 >51 Female 3-10 (22 .7 X W) - 495 (22 .5 x W) + 499 11-14 28 .5 1 .67 47 10-18 (17 .5 X W) + 651 (12 .2 X W) + 746 15-18 24 .9 1 .60 40 18-30 (15 .3 X W) + 679 (14 .7 x W) + 996 19-24 23 .2 1 .60 38 30-60 (11 .2 X W) + 879 (8 .7 x W) + 829 25-50 21 .9 1 .55 36 >60 (13 .5 X W) + 987 (10 .5 x W) + 596 >51 19 .7 1 .50 30 OWEN ET AL . Men : REE, resting energy expenditure; TEE, total daily energy expenditure . 879 + (10 .2 X W) Women : 795 + (7 .18 X W) IRETON-JONES ET AL . ments should be in the form of essential amino acids in Spontaneously breathing : normal adults. 629 - (11 X A) + (25 X W) - (609 X Q) Ventilator dependent: 1925 - (10 X A) + (5 X W) + (281 XG)+(292XT) + (851 X B) Nitrogen Balance A, age in years ; B, diagnosis of burn (present = 1, absent = 0) ; G, gender (male = 1, female = 0); H, height in centimeters ; 0, obesity (present = 1, absent Nitrogen balance is calculated as the difference between ni- = 0) ; T, diagnosis of traumas (present = 1, absent = 0) ; W, weight in kilograms . trogen intake, in the form of amino acids or protein, and nitrogen losses in urine, stool, skin, and body fluids .
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