clinical nutrition1/opm germany/stand 02 2003-01-09/1/96 opm. basic care. diabetic care....

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


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Significance of Nutrition

health

energy

well-being

body mass


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Energy Transfer

nutrients O2

NH3 CO2

H2O

chemical energy transfer

osmotic energy transport of substances

chemical energy biosynthesis, reactions

ATP

mechanical energy muscles


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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


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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


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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)


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- 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


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• 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


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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


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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)


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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


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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


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Areas of Resorption of Fats, Proteins and Carbohydratesstomach jejunum ileumduodenum

fat

protein

carbohydrates

resorption in reserve


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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


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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


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• carbohydrates

Nutrients

• fat

• protein

• dietary fibers

• vitamines

• minerals

• trace elements

• phytochemicals

Macronutrients Micronutrients

• water


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• 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


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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


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• 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


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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


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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)


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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)


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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


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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


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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


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• 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


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• 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)


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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


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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


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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


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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


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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


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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


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• 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


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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


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glucose glycogenesis glycolysisliponeogenesis

glycogenolysis

fat lipogenesis lipolysis

protein protein synthesis proteolysisgluconeogenesis

anabolism catabolism

Metabolic Pathways in Anabolism and Catabolism


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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)


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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.


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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


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survival without fluid intake: maximum of 3-4days

Function of Water

• solvent (dilution)

• transport medium

• temperature regulation (perspiration)


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Dietary Fibre

Carbohydrates, which cannot be broken

down by

the enzymes in the human intestinal tract

(indigestible) as well as lignin


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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


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Indigestible Constituents of Food

• are only indigestible for human digestive enzymes

• reach the colon virtually unchanged

• can be fermented by bacterial enzymes


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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)


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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


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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)


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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


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Long-Term Effects of Dietary Fibres

• Gall stones

• Inflammatory intestinal illnesses

• Ulcus duodeni

• Haemorrhoids

• Irritable intestine

• Colon carcinomas


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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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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)


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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)


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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


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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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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)


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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.)


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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)


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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


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FermentationIndigestiblecarbohydrates

- Polysaccharide

- Oligosaccharide

- Monosaccharide

Secretion productsCell constituents

Bacterial hydrolysisof the complex carbohydrates

LactateEthanolSuccinate

Bacterialfermentation

Bacterialbiomass

Short-chain fatty acids - Acetate - Propionate - Butyrate

GasesCarbon dioxideHydrogenMethaneH2S


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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


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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


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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


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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)


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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


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“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 ?


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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)


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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


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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


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Occurrence of Prebiotics

Oligo-fructose and inulin Resistant starches

Bananas MaizeChicory RiceGarlic BarleyLeeks WheatRye Leguminous plantsAsparagus PotatoesTopinambour BananasWheatOnions


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Structure of Prebiotics

Saccharose structure of oligo-fructose and inulin


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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


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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


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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


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Nutricomp Dietary Fibre Concept

Inulin 20 %

Soya dietary fibre30 %

Gum arabicum 20 %

Resistant starch 15 %

Cellulose 8 %

Pectin 7 %

insoluble 41 % soluble 59 %


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Basic Principles for Nutrient Intake

about 2 liters beverages about 30g dietary fibers

55%

30%15%

energy substrate distribution

carbohydrates

proteinfat


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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)


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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


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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


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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


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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


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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


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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


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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


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• 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


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Minerals

• sodium

• potassium

• calcium

• magnesium

• phosphate

• chloride


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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)


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Trace Elements

• iron

• zinc

• copper

• iodine

• chromium

• fluorine

• manganese

• molybdenum

• selenium

• cobalt


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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)


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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


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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


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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


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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


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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


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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


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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


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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

clinical nutrition1/opm germany/stand 02 2003-01-09/1/96 opm. basic care. diabetic care....

Documents

nutrition care

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basics of nutrition