NUTRIENTS and ASSESSMENT

1
NUTRIENTSand ASSESSMENT

• Myrna D.C. San Pedro, MD, FPPS

2
NUTRITION

• Combination of processes by which the living
  organism receives uses the materials necessary
  for growth, maintenance of functions repair of
  component parts

3
METABOLISM

• All the changes in the foodstuffs from
  absorption in the digestive tract until
  elimination by the excretory organs

4
Nutrient Requirement the amount to replace
obligatory losses support synthesis of new
tissues varies by age, sex, size growth rate

• Energy Requirement/Expenditure
• Basal Metabolic Rate (BMR)
• Specific Dynamic Action of food (SDA)
• Body activity
• Growth allowance
• Losses per excreta

5
Basal Metabolic Rate (BMR)

• Energy expenditure of an awake individual at rest
  in a thermoneutral environment after an overnight
  or 14 hours fasting
• Most closely related to lean body mass
• Factors metabolic disorders, surgery,
  infections, anorexia or fever for example, basal
  metabolism increases by about 10 for each
  centigrade of fever
• 50-100 of resting metabolic rate in infants and
  20-25 in adults goes to maintenance of
  temperature
• In infants about 55 kcal/kg/day which decreases
  to 25-30 kcal/kg/day at maturity

6
Specific Dynamic Action (SDA)

• The obligation to expend energy to digest
  assimilate food
• Highest for proteins lowest for carbohydrates
• About 5 kcal/kg/day

7

• Body activity (exercise physical activity)
  average allowance during the first year is 25
  kcal/kg/day
• Growth allowance during the first 4 months is
  about 15-20 kcal/kg/day which decreases to 12
  kcal/kg/day at the end of the first year
• Fecal loss 8 kcal/kg/day in the form of unused
  fats proteins

8
Thus, the energy requirement of the infant or
child is the level of intake which can
maintain appropriate body size composition
include deposition of new tissue
and the thermic effect of food
meet the energy required for physical activity
9
Daily Requirement

• Approximately 80-120 kcal/kg body weight for
  the 1st year of life with subsequent decreases of
  about 10 kcal/kg body weight for each succeeding
  3-year period

10
Recommended Dietary Allowances(RDAs, USA)

• Other terms are Recommended Dietary Intakes
  (RDIs, UK) and Safe Levels of Intake (FAO/WHO)
• The levels of intake of essential nutrients that
  are judged by the Food and Nutrition Board, based
  on scientific knowledge, to be adequate to meet
  the known nutrient needs of practically all
  healthy persons
• An important element is that recommended intakes
  must be adequate for population groups implying
  that safety margins are inherent in these
  recommendations

11
MAJOR NUTRIENTS

1. Carbohydrates
2. Proteins
3. Fats
4. Vitamins
5. Minerals
6. Water

12
Energy is provided by the following

• Carbohydrates
• 60 (45-65) of the diet
• 1gm provides 4 kcal
• Proteins
• 11 (9-15) of the diet
• 1gm provides 4 kcal
• Fats
• 35 (25-45) of the diet
• 1gm short-chain provides 5.3 kcal
• 1gm medium-chain provides 8.3 kcal
• 1gm long-chain provides 9 kcal

13
Carbohydrates Functions

1. Readily available source supply most of the
   bodys energy needs
2. Antiketogenic
3. Structure of cells
4. Store calories as glycogen
5. Convert to fat
6. Amino acid synthesis
7. Cellulose as roughage

14
(No Transcript)
15
Proteins Functions

1. Supply amino acids for growth repair of body
   tissues
2. Supply ions in acid-base balance
3. Part of hemoglobin, nucleoproteins, glycoproteins
   lipoproteins
4. As enzymes, hormones, antibodies cellular
   respiratory substance
5. Protective structure (nails hair)
6. Source of energy when there is shortage of fats
   carbohydrates

16
(No Transcript)
17
Daily Protein Requirement
2002 Dietary Reference Intakes (DRIs) Updates from the (US) Food and Nutrition Board of the National Academy of Sciences (gm/kg BW/day) 2002 Dietary Reference Intakes (DRIs) Updates from the (US) Food and Nutrition Board of the National Academy of Sciences (gm/kg BW/day) 1978 FNRI Publications, Daily Requirements of Filipinos (gm/kg BW/day) 1978 FNRI Publications, Daily Requirements of Filipinos (gm/kg BW/day)
0-6 mo ---- (2.2, WHO) 0-5 mo 3.5
6-11 mo 3
1 to 3 yr 1.1 1-2 yr 2.5
4 to 13 yr 0.95 (1 for 7 yr WHO) 3-6 yr 2
7-15 yr 1.5
14 to 18 yr 0.85 (0.75, WHO) 16-19 yr 1.2
As a point of reference, 3 ounces of lean beef, which is a serving the size of a deck of cards, provides 30 grams of protein. A cup of milk contains 8 grams of protein. As a point of reference, 3 ounces of lean beef, which is a serving the size of a deck of cards, provides 30 grams of protein. A cup of milk contains 8 grams of protein.
18
Essential Amino Acids

• Essential nutrient A substance necessary for
  normal metabolic functioning but cannot be
  synthesized by the body and must be obtained from
  the diet
• 24 amino acids identified
• 9 are found to be essential for children
  histidine, isoleucine, leucine, lysine,
  methionine, phenylalanine, threonine, tryptophan
  valine
• Arginine, cystine taurine are essential for LBW
  infants

19
Evaluating Protein Quality

1. Protein Efficiency Ratio (PER) Wt gained/gm
   protein consumed the U.S. FDA used the PER as
   the basis for the of the USRDA for protein on
   food labels but PER was based upon the a. a.
   requirements of growing rats, which are different
   from humans
2. Biologic Value (BV) of protein Amount of
   nitrogen accumulated compared with nitrogen
   absorbed indicates effectiveness of utilization
   but does not take into account certain factors
   influencing digestion
3. Net Protein Utilization (NPU) Percentage of
   nitrogen consumed that is retained by the body
   influenced by factors other than inherent a. a.
   composition such as reduced digestibility caused
   by overheating lowering protein value by
   decreasing availability of several essential a. a.

20
Evaluating Protein Quality

1. Amino Acid Score (AAS) A chemical technique
   measuring indispensable a. a. in a protein and
   comparing values with a reference protein
   considered fast, consistent, and inexpensive
2. Protein Digestibility Corrected Amino Acid Score
   (PDCAAS ) Amino Acid Score w/added digestibility
   component current accepted measure based on the
   amino acid requirements of humans limitations
   takes no account of where the proteins have been
   digested and may also be considered incomplete
   since human diets almost never contain only one
   kind of protein

21
Fats Functions

1. A concentrated reserve source of energy
2. Physical protection for vessels, nerves, organs
3. Insulate against changes in temperature
4. Structure of body tissues, cell membranes
   nuclei
5. Carry the fat-soluble vitamins (A, D, E, K)
6. Give appetite appeal
7. Aid satiety (delay emptying time of the stomach)
8. Spare protein
9. Supply linoleic acid, the essential fatty acid

22
(No Transcript)
23
Essential Fatty Acids (EFAs)

• Linoleic acid (LA) linolenic or alpha-linolenic
  acid (LNA or ALA) are the 2 EFAs LA can be
  converted to both arachidonic and linolenic acids
• Necessary for growth, skin hair integrity,
  regulation of cholesterol metabolism, lipotropic
  activity, decreased platelet adhesiveness and
  reproduction diets w/lt1-2 cal will affect
  growth rate, cause dry scaly rash w/ intertrigo
  and poor wound healing
• LA is abundant in soy oil, sunflower, safflower
  sesame seeds, corn oil, and most nuts while LNA
  is found abundantly in flax, small quantities in
  walnuts, cold pressed canola oil, wheat germ and
  dark green leafy vegetables
• The right ratio of LA to ALA in the diet, about
  31 or 21, is important an imbalance may lead
  to a variety of mental disorders, including
  hyperactivity, depression, brain allergies, and
  schizophrenia

24
Omega-3 and Omega-6 Fats

• Polyunsaturated fatty acids (PUFA) containing
  more than one cis double bond
• ALA (183n-3) belongs to the omega-3 family of
  fatty acids while LA (182n-6) belongs to the
  omega-6 family from these 2 EFAs can be
  manufactured other (non-essential) omega-3 and
  omega-6 fatty acids
• Important structural components of cell
  membranes, that, when incorporated into
  phospholipids, affect cell membrane properties
  such as fluidity, flexibility, permeability and
  the activity of membrane bound enzymes
• Lowers LDL cholesterol decreases CV disease
  risk
• Can modulate the expression of a number of genes,
  including those involved with fatty acid
  metabolism and inflammation

25

• Eicosanoids derived from DGLA, AA and EPA play
  critical roles in immune and inflammatory
  responses by being formed into prostaglandins and
  leukotrienes although EPA eicosanoids are less
  potent inducers of inflammation, blood vessel
  constriction, and coagulation than those derived
  from AA

26

• DHA and AA are high in the phospholipids of brain
  gray matter suggesting their importance to CNS
  function such that depletion of DHA in the brain
  can result in learning deficits
• Also, EPA and DHA supplementation during
  pregnancy has beneficial effects on long-term
  cognitive development in children
• DHA appears to be important for visual and
  neurological development but it is not yet clear
  whether feeding infants formula enriched with DHA
  and AA enhances visual acuity or neurological
  development in preterm or term infants
• There is evidence, though, that human conversion
  of EPA and, particularly DHA, is relatively
  inefficient suggesting that EPA and DHA may also
  be essential under some conditions

27
Vitamins

• Organic compounds in minute amounts that catalyze
  cellular metabolism
• 16 vitamins, 8 of which are considered necessary
  for human nutrition retinal, thiamin,
  riboflavin, niacin, cobalamin, folacin, ascorbic
  acid vitamin D
• There is presumptive evidence that pyridoxine
  tocopherol may be necessary for infant nutrition

28
Minerals

• Macrominerals
• Sodium 1gm or 2mEq/kg
• Potassium 1-2gm or 1.5mEq/kg
• Calcium 0.6gm/day
• Magnesium 150-300mg/day
• Chlorine 0.5gm/day
• Phosphorus
• Sulfur 0.5-1gm/day

• Microminerals
• Iron 1mg/kg/day
• Iodine 34-45 mcg/day
• Copper 0.5-1mg/kg/day
• Fluorine 0.5-1mg/day
• Zinc 3-5mg/kg/day
• Cobalt 1-2mcg/day
• Manganese 0.05-1.5mg/day
• Chromium 0.02-0.10mg/day
• Selenium 0.02-0.10mg/day
• Molybdenum 0.05-0.15mg/day

29
Macrominerals

• Sodium, Chloride, Potassium work together to
  regulate the flow of fluids in the body help
  regulate the nervous system, muscle functions
  nutrient absorption in the cells
• Calcium is needed for bone rigidity helps in
  blood clotting, muscle contraction normal nerve
  functions.
• Phosphorous aids in all phases of calcium
  metabolism helps build strong bones teeth
• Magnesium helps regulate body temperature, muscle
  contractions the nervous system helps cells
  utilize carbohydrates, fats, and proteins
• Sulfur helps in detoxification reactions is
  present in the amino acids in proteins a
  component of constituents of mucopolysaccharides
  essential compounds

30
Microminerals

• Iron combines with protein to form hemoglobin
• Iodine is needed by thyroid gland to produce
  thyroxine
• Copper is necessary in the formation of
  hemoglobin
• Fluorine helps reduce incidence of tooth decay
• Zinc plays an important role in the formation of
  protein, thus, assists in wound healing, blood
  formation and general growth maintenance of all
  tissues
• Cobalt is a component of vitamin B12
• Manganese is necessary for normal development of
  bones and connective tissues
• Chromium maintains normal glucose uptake into
  cells helps insulin bind to cells
• Selenium w/vitamin E protects cells from
  destruction
• Molybdenum is a component of xanthine oxidase and
  aldehyde oxidase

31
Water

• Essential for life
• Two-thirds of body weight, 75-80 in infants
  while 55-60 in adults
• Daily consumption by a healthy infant is 10-15
  BW versus 2-4 BW in adult
• Of fluid intake water retention 0.5-3,
  evaporation from lungs skin 40-50, fecal
  losses 3-10 renal excretion about 40-50 or
  more
• Fruits vegetables 90 water

32
ASSESSMENT OF NUTRITIONAL STATUS OF CHILDREN

• History
• Dietary history of mother child
• History of height weight changes
• Anthropometric indicators
• Evidence of deviations from average height
  weight
• Evidence of depletion of fat depots
• Evidence of decrease in muscle mass
• Change in psychic reaction
• Reaction to infection
• Evidence of specific deficiencies

33
ANTHROPOMETRIC INDICATORS OF NUTRITIONAL STATUS

• Weight index of acute nutritional status
• Height or length unaffected by excess fat or
  fluid assesses growth failure
• Weight for height measurement more accurately
  assesses body build
• Measure childs height
• Find age for which measured height is on the 50th
  on the growth curve
• Childs actual weight (numerator)
• 50th wt based on age of plotted ht
  (denominator)

34

• Head circumference influenced by nutrition till
  age 36 mo measurements lt 5th may indicates
  chronic undernutrition during fetal life early
  childhood
• Skinfold thickness(TSF) provides an estimation
  of total body fat
• Mid-arm circumference (MAC)/Mid-arm muscle
  circumference (MAMC) with TSF, determines muscle
  area fat area
• MAMC MAC (3.4 x TSF)
• Bone age epiphyseal closure percentage of
  maturity attained indicates potential for
  catch-up growth

35
Growth Velocity (GV)

• Evaluates change in rate of growth over a
  specific time period expressed in cm/yr more
  sensitive way of assessing growth failure or
  slowed growth
• Formula
• GV (cm) H2 (cm) H1 (cm)
• T (yr)
• where
• H1 initial height in centimeters
• H2 height at next measurement
• T period between two measurements in
  years

36
Body Mass Index (BMI)-for-Age

• An effective screening tool specific for age and
  gender but not a diagnostic tool
• Formula Weight (kg)/Height (m)2
• Calculation weight (kg)/ height (cm)/height
  (cm) x 10,000
• BMI-for-age cut-offs
• gt 95th Overweight
• 85th - lt 95th Risk of overweight
• lt 5th Underweight
• BMI-for-age correlates w/ clinical
• risk factors in CVS disease such as
• hyperlipidemia, elevated insulin
• high blood pressure during middle age

37
Can you see risk?
A Overweight
B Normal
C At risk for overweight
Age3 y 3 wks boy Height100.8 cm Weight18.6
kg BMI18.3 BMI-for-age gt95th
Age4 y girl Height99.2 cm
Weight17.55 kg BMI17.8 BMI-for-age between
90th 95th
Age 4 y 4 wks girl Height106.4 cm Weight15.7
kg BMI13.9 BMI-for-age 10th
38
BMI-for-Age
A
C
B

• During early childhood, BMI decreases reaching a
  nadir (the so-called rebound point) between 4 and
  7 years of age, then increases to 20 years of age
  reflecting the normal changes in body composition
  during puberty.

39
RELAX !!!