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Energy balance
Nutritional Screening and Assessment
Lubos SobotkaCharles University - Medical Faculty
Hradec KraloveCzech Republic
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Learning Objectives
To the principles of measurement of energy expenditure
To now how to diagnose a risk of malnutrition
To know the methods for measurement of body composition
To be able to estimate energy intake in hospitalized patients
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Flow of energy in biosphere
H2O + CO2
ATPphotosynthesis
CHOFatProteins
N
H2O + CO2
+N
O2 O2
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Energy expenditureFOOD
O2
CO2H2ONitrogen
CHOFatProteins
HeatBODY RESERVES
Total energy expenditure - TEE
resting energy expenditure - REE
diet induced energy expenditure - DEE
activity induced energy expenditure - AEE
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Resting energy expenditure ∼ 60-70%
Diet induced energy expenditure ∼ 10%
Activity induced energy expenditure ∼ 60-70%
Components of energy expenditure-adult person-
Maintaining cell membrane ion gradientsConstant protein synthesis and breakdownAmino acid metabolism Glycogen synthesis and breakdown Fatty acids cycleGluconeogenesisEnergy for breathing and heart function
An postprandial increase in EE above basal fasting levelLasts for several hours after meal
Is the most variable component of TEEDependent on physical activity
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Energy expenditure measurement
Direct calorimetry
Measurement of heat produced during energy processes
Indirect calorimetry
Measurement: O2 consumptionVO2 production
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Direct calorimetry
Whole body heat production
Special chambers difference in heat coming into and out of the chamber
T1
T2
V
V
EE ∼ ∆Q = V (T2 – T1)
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Indirect calorimetry
Measurement of O2 consumption VO2
production
cO2, cCO2
V
VcO2, cCO2
EE ∼ VO2 consumption and VCO2 production
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Indirect calorimetry
flow
gasmeter
CO2-analyser
O2-analyser
² CO 2 ² O 2outdoor air
outdoor air
respiratory air
ventilated hood or
respiration chamber
Westerterp K, Schols A Basics in Clinical Nutrition, 2004
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Ventilated hood - canopy
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Indirect calorimetry
VO2 = 0.829 CHO + 2.02 Fat + 6.04 NitrogenVCO2 = 0.829 CHO + 1.43 Fat + 4.84 Nitrogen
Substrate oxidation:CHO = 4.59 VCO2 – 3.25 VO2 – 3.68 NitrogenFat = 1.69 VO2 – 1.69 VCO2 – 1.72 NitrogenProtein = 6.25 Nitrogen
Energy expenditure:EE = 3.87 VO2 + 1.19 VCO2 – 5.99 N
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Indirect calorimetry
Energy expenditure can be calculated both from VO2 and VCO2:
Calculation from VO2 and VCO2:EE = 3.95 VO2 + 1.11 VCO2
Calculation from VO2:EE = VO2 (3.95 + 1.11 RQ) – moderately dependent on RQ
Calculation from VCO2:EE = VCO2 (1.11 + 3.95/RQ) – Highly dependent on RQDoubly labeled water, labeled bicarbonate
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80,0
85,0
90,0
95,0
100,0
105,0
110,0
115,0
120,0
0,7 0,75 0,8 0,85 0,9 0,95 1
RQ
Diff
eren
ce in
RE
E [%
]
VCO2VO2VO2 a VCO2
Relationship between REE and RQ [REE calculation based on VO2 or on VCO2]
REE calculated from VCO2 is more dependent on RQ (possible mistake 15%) then if calculated from VO2 (possible mistake 4%)
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Measurement of EE using doubly labeled water
2H 18O2
2H 18OLabels water pool
Labels water and bicarbonate pools
2HHO H 18O CO 18O2
H2OK2 = r H2OCO2+ rK18 = r
K18 - K2 = r CO2
Principle of the doubly labelled water (2H218O) method for the measurement of
carbon dioxide production (rCO2) from the elimination rates of 18O (k18) and 2H (k2). The elimination rate of 2H is a function of water loss (rH2O) while k18 is a function of rCO2 and rH2O.
Westerterp K, Schols A Basics in Clinical Nutrition, 2004
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0,00
2,00
4,00
6,00
8,00
10,00
12,00
40 50 60 70 80 90 100 110 120 130 140Heart rate [b/min]
Ener
gy ex
pend
iture
[kca
l/min
.]
Relationship between heart rate and energy expenditure
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Relationship between heart rate and energy expenditure –whole group
0
2
4
6
8
10
12
14
75 95 115 135 155 175
Heart rate [b/min]
Ene
rgy
expe
nditu
re[c
al/m
in.]
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0
2
4
6
8
10
12
14
16
18
95 105 115 125 135 145 155
Heart rate [b/min]
Ener
gy ex
pend
iture
[cal/
min
.]
Relationship between heart rate and energy expenditure –individual patients
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Harris-Benedict equations
The most common approach to predict resting energy expenditure
Male: REE = 66.5 + (13.8 x weight) + (5.0 x height) - (6.8 x age)
Female: REE = 655.1 + (9.6 x weight) + (1.8 x height) - (4.7 x age)
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The theoretical reserves of a 74 kg man
Body substrate Substrate weight( kg )
Energy content( kcal )
Fat 15 141.000Protein 12 48.000Glycogen (muscle) 0.5 2000Glycogen (liver) 0.2 800
Total 191.800
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Prevalence of undernutrition• Ambulatory outpatients 1-15%• Institutionalized patients 25-60%• Hospitalized patients 35-65%
• These rates depend on how malnutrition is defined
Omran et al, Nutrition 2000
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Assessment of
Nutritional status
1. Screening
2. Assessment
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ESPEN Guidelines for Nutrition Screening
• All patients should be screened on admission to the hospital
• If the patient is at risk, a nutrition plan is worked out by the staff
• Monitoring and defining outcome has to be organized
• Results of screening, assessment and nutrition care plans should be communicated to healthcare professionals to which the patient is transferred
• Outcome should be audited and communicated to furnish the data on which future policy decisions can be made
Nutrition Screening 2002, Clin Nutr 2003www.espen.org → Education → Guidelines
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Nutritional screening
Is a tool to rapidly and simplyevaluate whether the patient is at risk to be or to becomemalnourished
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Nutritional screening
History:• Weight loss over time• Anorexia, nausea• Food intakeFirst measurements:• Body weight• Height
BMI (kg/m2)
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Screening tools• Nutritional Risk Index1 - biochemical• Subjective global assessment2
• Malnutrition Universal Screening Tool (MUST)3
• Nutritional Risk Screening (NRS 2002)4
• MNA (elderly)5
1 Veterans Affairs, New Engl J Med 1991
2 Detsky et al, JPEN, 1984
4 Kondrup et al, Clin Nutr 2003
5 Vellas et al, Nutrition 1999
3 BAPEN
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Nutritional risk screeningSubjective global assessment (SGA)
I Patient‘s history(weight loss, change in dietary intake, gi-symptoms,functional capacity)
IIPhysical examination(muscles, subcutaneous fat, edema, ascites)
Clinician‘s overall judgment• good nutritional status• moderate malnutrition• severe malnutrition
Detsky et al, JPEN, 1984
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ESPEN guidelines for nutrition screening 2002
Part 1
Kondrup J et al. ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003
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Part 2
Kondrup J et al. ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003
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Nutritional Assessment
Is the actual measurement of nutritional state and has to be donein patients that are considered to be atrisk by the nutritional screening
orwhen metabolic or functional problemsprevent a standard plan being carried out
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Normal body composition
• Normal body cell mass (BCM) is the major determinant of an adequate nutritional state: – Living, actively metabolizing part of the body– Extra-cellular mass may increase
disproportionately in malnutrition, disease, whereas fat free cell mass decreases
• Normal macronutrients, electrolytes, trace-elements, vitamins
• Normal organ sizes
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What can be measured?
• Fat body massBody fat percentageFat distribution (visceral fat)
• Lean body massWater: extra and intracellularBody cell massMuscle massBone
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The two compartments model
Fat mass
Fat free body mass
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The four compartments model
Fat mass
Fat free body mass
• body cell mass• extra-cellular water
• bone
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Body composition changes in normal adult males
Body fat (kg)Muscle (kg)Age (years)
152420-29
192040-49
231760-69
251370-79
Young 1992
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Underwater weighing
Fat mass Fat-free mass
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Dilution method – deuterium/bromide
Deuterium –TBW
Bromide-ECV
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Anthropometry
Muscle-mass
Fat-mass
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Anthropometry
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Anthropometric measurement
• Validation only partially performed• Large inter-individual variability• Good intra-individual variability if the investigator is properly trained
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Creatinine excretion in urine • Creatinine excretion correlates with lean body mass and body weight
• 18-20 kg of muscle produce 1 g of creatinine
• Dietary protein sources contribute up to 20% of excreted creatinine
• Urinary creatinine excretion is proportional to skeletal muscle mass (stable renal function; no dialysis or hemofiltration)
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Norm values for urinary creatinineexretion/mg/24h
Norm/men
Urina
ry c
reat
inine
(mg/
24h)
Height (cm)
Norm/women
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Urinary creatinine excretion is influenced by:
• Decreasing renal function; oliguric renal insufficiency
• No meat consumption↳ low creatinine excretion
• High meat consumption• High physical activity• Catabolism
– fever– infection– trauma
↳high creatinine excretion• Incomplete 24 h-urine sampling
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Body fat distributionand waist circumference
• Measured at the mid-point between the ileac crest and the lower rib
• Correlates strongly with intra-abdominal adipose tissue as assessed by CT and MRI
• Upper body obesity defined as a waist circumference: – ≥ 102 (94) cm for men – ≥ 88 (80) cm for women
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Bioelectrical impedance analysis (BIA)
• BIA allows the determination of - Fat-free mass and- Total body water
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ESPEN - GUIDELINESBioelectrical impedance analysis
Fat-free mass andTotal body water
1) Review of principles & methods.Clin Nutr 2004; 23: 1226-1243
2) Utilisation in clinical practice.Clin Nutr 2004; 23: 1430-1453
www.espen.org/education
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Bioelectrical impedance analysis (BIA)
• BIA allows the determination of - FFM on the basis of TBW measurement
• in subjects without significant fluid and electrolyte abnormalities when using appropriate equations (age, sex, race)
• BIA in subjects at extremes of BMI ranges (16-34 kg/m2) or with abnormal hydration status is not reliable
• Disease almost always includes inflammatory activity (ICW/ECW ratio decreases; TBW increases; BIA unreliable)
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Dual energy X-ray absorptiometry (DEXA)
• Three-compartment model
• Fat mass, free-fat mass and bone
• State of hydration may affect results
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MRI or CT scan
• Fat mass
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Creatinine excretion in urine • Creatinine excretion correlates with lean body mass and body weight
• 18-20 kg of muscle produce 1 g of creatinine
• Dietary protein sources contribute up to 20% of excreted creatinine
• Urinary creatinine excretion is proportional to skeletal muscle mass (stable renal function; no dialysis or hemofiltration)
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Muscle strength
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Muscle strength• Is a good predictor of outcome:
– In chronic situations:• Aging• Organ failure (renal failure, COPD,
heart failue….
– In acute situations:• Surgery or trauma• Second hit (superimposed infection when already subject to inflammatory activity)
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SummaryPractical methods for measuring: Fat mass
• Subcutaneous skin folds measurements
• DEXA• MRI, CT scan• BIA
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SummaryPractical methods for
measuring: Fat-free mass
• DEXA• BIA• (Underwater weighing)
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SummaryPractical methods for
measuring: Body cell mass
• (Total body potassium)• (Nitrogen neutron activation)
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SummaryPractical methods for
measuring: Muscle mass
• Mid-arm circumference• Creatinine height index• Urinary 3-Methylhistidine
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SummaryPractical methods for measuring: Body-water
• Total body water(- Isotopic labeling of water)- BIA
• Extracellular water(- Bromide space)
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SummaryPractical methods for measuring:
Bone mass
• DEXA• Total body calcium-measured
by isotopes methods
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Inflammatory and disease activity
Disease always includes inflammatoryactivity• Clinical evaluation
- Pre-existing inflammation or disease • Plasma Albumin levels
- Already significant when ≤ 35 g/L• Cytokine levels (TNF-α, IL 6, ...)• CRP
- Very volatile, is a rough correlations, but notsuitable for the individual patient
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Serum proteins
• Albumin (T½): 20 days• Transferrin (T½): 8-10 days• Transthyretin (T½): 2-3 days
(Prealbumin) • Retinol-binding protein (T½): ∼ 12 h
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Wound healing is dependent of endogenous substrates
Undernutrition
poor wound healing(dehiscence, infections)
Loss body cell mass
Deficit endogenous substrates for wound
healing.
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Complicated surgical wound
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Complicated operation wound
Granulation stimulation
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Complex treatment
Wound before the last operation
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A sterile gauze poured byhyaluronan-iodine complex
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Infectious complications and albumin
Kudsk et al, JPEN 2003
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How to measure food intake
• Bomb calorimetry of food before and after meal (double plate method)
• Weighing of food before and after meal • Quarter plate method
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Quarter plate method
• Standard meal
• 2000 kcal• 60 g protein• 290 g CHO• 70 g fat
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Calculate energy and protein intake – he eats ¼ of servings
• Standard meal
• 2000 kcal• 70 g protein• 280 g CHO• 70 g fat
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Calculate energy and protein intake – he eats ¼ of servings
• Standard meal
• 2000 kcal• 70 g protein• 280 g CHO• 70 g fat
• Daily intake
• Energy – 500 kcal• Protein – 24 g
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Calculate daily energy balance
• Energy balance EB:
EB = EI – TEE
EB = 500 – 1800 = -1300 kcal/day
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Calculate daily need of supplements
• Energy deficit: 1300 kcal/day• Protein deficit: 30.4 g day
Standard supplement (sipping) = 150 kcal & 6 g Prot/100 mlRecommendation = 1000 ml of standard nutrition (e.g. sipping)
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Thank you!