Nutrisi Utama &

Kebutuhan

Dr.Brain Gantoro, M.Gizi, SpGK

Normal Nutrition (EatRight.org)
 The Newest Food Guide
Pyramid

Balancing Calories Enjoy your food, but eat less. Avoid oversized portions.
Foods to Increase Make half your plate fruits and vegetables. Make at least half
your grains whole grains. Switch to fat-free or low-fat (1%) milk.
Foods to Reduce Compare sodium in foods like soup, bread, and frozen meals
and choose the foods with lower numbers. Drink water instead of sugary drinks.

Website: http://www.choosemyplate.gov/
Includes interactive tools including a personalized daily food plan and food tracker
Normal Nutrition

Requirements

HEALTHY male/female
(weight maintenance)
Caloric intake=25-30 kcal/kg/day
Protein intake=0.8-1gm/kg/day
(max=150gm/day)
Fluid intake=~ 30 ml/kg/day
 NUTRIENTS
6 Classes

Carbohydrates Vitamins
Protein Minerals
Fat Water
These 3 provide These 3 provide no
energy (calories) and energy, but are
are used for various essential to life.
body functions.
 Carbohydrates
Provide/yields 4 kcals/gram (3.4 kcal/gm dextrose
in parenteral nutrition)
Provide fuel for most cells in body
Main ; Richest sources: grains, fruits, beans ;
veggies, & dairy foods
Complex versus simple
Limited storage capacity, needed for CNS
(glucose) function
Recommended 45-65% total daily calories.
 Fat
Recommendations
Main sources include oil, nuts, butter, milk and cheese
Major endogenous fuel source in healthy adults
Rich source of energy, 9 kcal/gram
Recommended 20-30% of total caloric intake
Dietary guidelines recommend <30% of total calorie intake, limit
saturated fats.
Fat is needed but not in excessive amounts
Too little can lead to essential fatty acid (linoleic acid) deficiency
and increased risk of infections
Needed to transport fat soluble vitamins
Excesses lead to obesity, heart disease
Saturated fats believed to be related to heart disease
Cushions & protects internal organs
Forms part of all cell membranes
 Protein
Main/riches sources include fish, meat, beef, poultry and
dairy products
Beans, grains, veggies provide some
Yields 4 kcal/gm
Must adjust in patients with renal and hepatic failure
Recommended 10-35% of total caloric intake.
Needed to maintain anabolic state (match catabolism)
Major structural component of bodys cells & tissues
Forms part of hormones, enzymes, antibodies
Needed for growth & repair of body tissues
 Vitamins & Minerals
Vitamins Minerals
needed in small major structural
amounts component of human body
(skeleton)
controls reactions in forms part of enzymes
the body & regulates used in many functions
body processes some needed in larger
each vitamin has amounts versus smaller
specific function amounts, but all equally
important
 Water
Most vital of all nutrients
Can survive without others much longer
than water
Part of chemical reactions
Lubricate joints
Cushions organs
Temperature regulation
Nutrients Often Lacking
in Teen Diets
Calcium
Iron
Zinc
Vitamin A
Vitamin C
Folate
 Micronutrients
Micronutrients are needed in much smaller amounts than the
macronutrients.

In general vitamins are needed to regulate the maintenance and

growth of the body, and to control metabolic reactions in cells.

Most vitamins are provided to the body through the diet, however,
the body can make vitamin D, vitamin K and niacin.
 Vitamin A (retinol, carotene)
Vitamin A is fat-soluble vitamin needed for the normal structure
and functioning of the cells in the skin and body linings, e.g. in
the lungs.
This vitamin also helps with vision in dim light, as well a keeping
the immune system healthy.
It is found in two forms; retinol in foods from animal
sources and carotenoids (the most abundant of which
is the beta-carotene) from plant sources.
Vitamin A retinol is found in liver and whole milk,
Vitamin A carotenoids are found in dark green leafy
vegetables, carrots and orange coloured fruits.
 Too much or too little?
Deficiency leads to poor vision in dim light or night blindness.
Severe deficiency can lead to total blindness.
May increase susceptibility to some cancers, skin, lung and
bladder
Most processed snack foods/fast foods are low in Vit A
Vitamin A is stored in the liver and too much vitamin A can be
toxic.
Consuming too much vitamin A whilst being pregnant has been
linked to birth defects.
 Vitamin D (Cholecalciferol)
Vitamin D is needed for the absorption of calcium and phosphorous
from foods, to keep bones healthy.

Recent research also suggests that vitamin D enhances immune

function and improves muscle strength.

Vitamin D is found in the diet, but most of our vitamin D is made

in the body the action of ultra violet rays on the skin.

Vitamin D occurs naturally in some

animal products, including fish liver oils,
oily fish, egg yolk, and butter.
Cereals, margarine and low fat spreads
are also fortified with vitamin D.
 Too much or too little?

Deficiency of vitamin D leads to rickets and the formation of soft

bones. This causes the bones in the legs to bend. Deficiency in adults
causes Osteomalacia resulting in pain and muscular weakness.

Vitamin D can be stored by the body. Too much vitamin D can lead
to excess levels of calcium in the blood.

Young children, housebound older adults, and people who practice

religions where their skin must be covered, may be at risk of
deficiency through lack of exposure of their skin to sunlight.
 Vitamin E (Tocopherol)
Vitamin E is a group of similar molecules with common properties
and functions.

Vitamin E acts as an antioxidant and protects cells in the body

against damage.

Vitamin E is mainly found in vegetable oils, nuts,

seeds and wheat germ.
 Deficiency and excess of vitamin E

A deficiency in this vitamin is rare because it is so widely

available in the diet.

In very rare cases neurological disabilities such as lost reflexes

have developed.

Vitamin E has a low toxicity, but in very large doses may interfere
with absorption of vitamin A.
 Vitamin K
Vitamin K is needed for normal clotting of blood and is
also required for normal bone structure.

Infants are given vitamin K at birth.

Vitamin K is also produced by the bacteria in the gut.

Vitamin K is found in green leafy vegetables e.g.

broccoli, lettuce, cabbage, spinach and meat and
dairy products.
 Too much or too little?

Deficiency of vitamin K is rare in

adults, but is sometimes seen in new
born babies.
 Thiamin (B1)
Thiamin is needed for the release of energy from carbohydrate. It
is also involved in the normal functioning of the nervous system
and the heart.

Thiamin is mainly found in whole grains, nuts,

meat (especially pork), fruit and vegetables and
fortified cereals.
 Too much or too little?
Thiamin deficiency can lead to the development of the disease
beri-beri. Symptoms include fatigue, weakness of the legs and
anorexia.

As the body excretes any excess thiamin, there is no evidence of

any toxic effects of high doses.
 Riboflavin (B2)
Riboflavin is needed for the release of energy from carbohydrate,
protein and fat.

It is also involved in the transport and metabolism of iron in the

body and is needed for the normal structure and function of skin
and body linings.

Riboflavin is found in milk, eggs, rice, fortified

breakfast cereals, liver, legumes, mushrooms and
green vegetables.
 Too much or too little?
There is no deficiency related disease, however, the tongue, lips
and skin become affected when the body is low in riboflavin.

As the body excretes any excess thiamin, there is no evidence of

any toxic effects of high doses.
 Niacin (B3)
Niacin is important for releasing energy from food, and is
important for the normal structure of the skin and body linings.

Niacin is also needed for the normal functioning of the nervous

system.

Niacin can be found in meat, wheat and maize flour,

eggs, dairy products and yeast.
 Too much or too little?

Deficiency of niacin can result in the disease pellagra. Symptoms

can include:
dermatitis;
dementia;
diarrhoea.

Problems associated with excessive intakes are rare.

 Vitamin B12
Vitamin B12 is needed for the formation of red blood
cells and the normal functioning of the nervous system.

Vitamin B12 also helps to release energy from food.

Vitamin B12 is found exclusively in animal

products, plant products do not provide any
vitamin B12.
It is found in meat, fish, cheese, eggs, yeasts
extract and fortified breakfast cereals.
 Deficiency of vitamin B12

Deficiency of vitamin B12 can lead to pernicious anaemia.

It can also lead to some neurological problems.

Deficiency is rare, but may be a problem for people following

strict vegan or vegetarian diets.
 Folate (Folic acid)
Folate is important for the formation of healthy red blood cells.

It is also needed for the nervous system and specifically for the
development of the nervous system in unborn babies.

It can reduce the risk of neural tube defects in a fetus, e.g. spina
bifida.

Good sources of folate include green leafy

vegetables brown rice, peas, oranges, bananas and
fortified cereals.
 Deficiency of folate
Deficiency of folate can lead to megaloblastic anaemia. Symptoms
can include insomnia, depression and forgetfulness.

It is recommended that all women who are planning a pregnancy

take a daily supplement of folic acid. Once pregnant,
supplementation should continue for the first 12 weeks to reduce
the risk of neural tube defects.
 Vitamin C (Ascorbic acid)
Ascorbic acid is needed to make collagen which is required for the
normal structure and function of body tissues, such as skin,
cartilage and bones.

It also acts as an antioxidant that protects the body from damage

by free radicals.

Sources of ascorbic acid include fresh fruits,

especially citrus fruits and berries, green
vegetables, peppers and tomatoes. Ascorbic acid is
also found in potatoes (especially in new potatoes).
 Too much or too little?
Scurvy can result from lack of ascorbic acid. It tends to occur in
infants and the older adults.
Scurvy leads to spots on the skin, bleeding gums and loose or loss
of teeth.
Tiny hemorrhages in skin
Decreased appetite and growth

Over nutrition of ascorbic acid is rare.

 Minerals
Minerals are inorganic substances needed by the body for many
different functions.

Some minerals are needed in very tiny amounts, these are known
as trace elements, such as fluoride.
 Calcium (Ca)
Calcium is important for the formation and maintenance of strong
bones and teeth, as well as the normal functioning of nervous
system and muscles.

It is also involved in blood clotting.

Good sources:
Milk products, yogurt, cheese, cottage cheese
Dark green leafy veggies
Fish with soft edible bones: sardines & salmon with bones
Bread, calcium enriched soya products
 Too much or too little?
Poor intakes of calcium can result in poor bone health which can
increase the risk of diseases such as osteoporosis later in life
(possibly porous or brittle bones)

Taking high doses of calcium supplements can cause stomach

pains and diarrhoea.
 Iron (Fe)
Iron is needed for needed for the formation of haemoglobin in
red blood cells which transport oxygen around the body.
It is also required for energy metabolism and has an important
role in the immune system.

Haem iron is present in animal sources in the form of haemoglobin:

Liver, red meats.
Egg yolk.
Non haem iron is present in plant sources: beans, peas,
nuts, dried fruits, wholegrains, soya bean flour and dark green leafy
vegetables.
Enriched, fortified or whole grain breads/cereals
 Too much or too little?
A lack of iron will lead to anaemia, especially common in girls.
Symptoms include:
feeling of tiredness;
lacking in energy;
general weakness;
poor concentration.

Too much iron in the diet can result in constipation,

nausea and vomiting.
 ZINC
If deficient: Good sources:
Growth retardation Meat, liver
Poor male sexual Eggs
development Sea food
Often a problem in Whole grain
vegetarians cereals
Poultry
 Phosphorus (P)
Phosphorus is essential for the structure bones and teeth, for the
structure of cell membranes and for energy metabolism.

Phosphorus is found in red meat, dairy products,

fish, poultry, bread, rice and oats.
 Potassium (K)
Potassium is essential for water and electrolyte balance and
normal functioning of cells, including nerves.

Potassium is present in all foods, but found richly in

fruit (dried fruits, bananas, berry fruits), leafy green
vegetables (e.g. broccoli and spinach) meat, nuts,
seeds and pulses.
 Sodium (Na)
Sodium is needed to regulate body water content and electrolyte
balance.

Sodium is also needed for the absorption of some nutrients and

water from the gut.

Sodium is present in very small amounts in raw

foods. It is often added as salt during
processing, preparation, preservation and
serving.

High salt processed foods include bacon,

cheese, yeast extract and smoked fish.
 Too much or too little?
Consuming too much sodium increases the risk of high blood
pressure. High blood pressure is linked with an increased risk of
heart disease and stroke.

Sodium deficiency is unlikely, but can be caused by excessive

sweating or vomiting and diarrhoea.

It is recommended that adults and children over the age of 11

years cut down on salt and consume no more than 6g per day.
 Fluoride (F)
Fluoride is needed for the formation of strong teeth and protects
against dental decay (caries).

Fluoride is a trace element, therefore only a small amount is

required for good health.

Fluoride can be found in drinking water and in

small amounts in tea and saltwater fish.
Some areas add fluoride to the drinking water.
Fluoride toothpastes are another important
source.
 Too much or too little?

An excessive intake of fluoride can lead to mottling or

discolouration of teeth.
 Nutrient interactions
Some nutrients work together in the body completing different
functions.

For example:
the vitamins A,C and E;
calcium phosphorus and fluoride;
calcium and vitamin D;
iron and vitamin C;
carbohydrates and B vitamins.
 Anti-oxidants
Vitamins A, C and E are anti-oxidants and work together in the
body to protect cells against oxidative damage from free radicals.

This damage to cells can increase the risk of developing diseases

such as heart disease and cancer.
 Calcium, phosphorus and fluoride

These nutrients are involved in the mineralisation of teeth and

bones which keep them hard and strong.

Vitamin D and calcium

Vitamin D controls the amount of calcium available.

A lack of vitamin D in the body results in reduced
absorption of calcium.
 Iron and ascorbic acid
Ascorbic acid aids the absorption of non haem iron (non meat
sources of iron) when eaten at the same time.

This is particularly important for people following strict vegan or

vegetarian diets.
 Carbohydrates and Vitamins B

Riboflavin and thiamin are involved in

the release of energy from
carbohydrate.
 Food Guide Pyramid
Developed by the USDA & Department of
Health & Human Services (HHS)
Framework for healthy eating for all ages
that can be followed a lifetime
Flexible - range of servings
Promotes moderation and variety in your
diet
 Food Guide Pyramid
Food Groups
Bread, Cereal, Rice & Meat, Poultry, Fish,
Pasta Group, 6-11 Dry Beans, Eggs &
servings (teens 9-11) Nuts Group, 2-3
Fruit Group, 2-4 servings (teens 2-3)
servings (teens 3-4) Milk, Yogurt & Cheese
Vegetable Group, 3-5 Group, 2-3 servings
servings (teens 3-4) (teens 3-4)
Fat, Oils & Sweet, use
sparingly
 Basis of Food Groups
Foods within each group have similar
nutrient contents
Different food groups have different
nutrient strengths and weaknesses
Combined food groupscan
supply all the nutrients needed
 Varying Amounts of
Nutrient Density
A soda and a bowl of watermelon
Each provide about 150 calories
Watermelon offers a little protein, some
vitamins, minerals & fiber along with
the energy
Soda provides empty calories
Watermelon or any fruit is more
nutrient dense than a soda
Breads, Cereals & Other Grains
Food Group
Characteristics:
provides complex carbs, riboflavin, thiamin,
niacin, iron, protein, magnesium & fiber
Foods highest in Nutrient Density:
whole grains (wheat, oats, barley, rye),
enriched breads, rolls, tortillas, cereals,
bagels, rice, pastas (macaroni/spaghetti)
Breads, Cereal & Other Grains
Food Group
Moderate in Nutrient Density (2nd
Choices):
pancakes, muffins, cornbread, crackers,
cookies, biscuits, presweetened cereals, taco
shells, waffles
Lowest in Nutrient Density (limit these):
croissants, fried rice, doughnuts, pastries,
cakes, pies
 Breads, Cereals & Other Grains
Serving Sizes
1 slice of bread 1 small roll, biscuit,
1/2 cup cooked cereal, muffin
rice, or pasta 3-4 small crackers or 2
1 oz ready to eat cereal large crackers
1/2 bun, bagel or
English muffin
 Vegetables Food Group
Characteristics:
provides Vitamin A, Vitamin C, folate,
potassium, magnesium, fiber.
low in fat and cholesterol
Highest in Nutrient Density:
bean sprouts, broccoli, brussel sprouts, cabbage,
corn, carrots, cauliflower, green beans/peas, leafy
green veggies, potatoes, tomatoes, winter squash
 Vegetables Food Group
Moderate in Nutrient Density (2nd
choices):
candied sweet potatoes
Lowest in Nutrient Density (limit these):
french fries, tempura veggies, scalloped
potatoes, potato salad
 Vegetable
Serving Sizes
1/2 cup cooked or raw
vegetables
1 cup leafy raw
vegetables
1/2 cup cooked
legumes
3/4 cup veg. juice
 Fruits Food Group
Characteristics:
provides Vitamin A, Vitamin C, potassium &
fiber
low in sodium, fat & cholesterol
Foods Highest in Nutrient Density:
apricots, cantaloupe, grapefruit, oranges, OJ,
peaches, strawberries, apples, bananas, pears,
unsweetened juices
 Fruits Food Group
Foods Moderate in Nutrient Density:
canned or frozen (in syrup)
sweetened juices
Foods Lowest in
Nutrient Density:
dried fruit
coconut, avocados
 Fruit Serving Sizes

1 medium apple, 1/2 cup diced,

banana, or orange cooked or canned
1/2 grapefruit, 1 fruit
melon wedge 1/4 cup dried
3/4 cup juice fruit
1/2 cup berries
Meat, Poultry, Fish, Dry Beans,
Eggs, & Nuts Food Group
Characteristics:
provides protein, phosphorus, Vitamin B6,
Vitamin B12, Zinc, Magnesium, Iron,
Niacin, & Thiamin
Highest in Nutrient Density:
poultry (light meat, no skin), fish, shellfish,
legumes, egg whites
Meat, Poultry, Fish, Dry Beans,
Eggs & Nuts Food Group
Moderate in Nutrient Density:
lean meat (fat trimmed beef, lamb, pork),
poultry (dark meat, no skin), ham, refried
beans, whole eggs,
Lowest in Nutrient Density:
hot dogs, luncheon meat, ground beef, peanut
butter, nuts, sausage, bacon, fried fish or
poultry, duck
Meat, Poultry, Fish, Dry Beans,
Eggs & Nuts Serving Sizes
2-3 oz lean, cooked meat, poultry or fish
1 egg
1/2 cup cooked legumes
4 oz tofu
2 tbsp nuts, seeds,
peanut butter as 1 oz meat
(about 1/3 serving)
 Milk, Yogurt & Cheese
Food Group
Characteristics:
provides calcium, riboflavin, protein, vitamin
B12, and when fortified, Vitamin D & A
Highest in Nutrient Density:
nonfat & 1% low-fat milk (& nonfat products
such as buttermilk, cottage cheese, cheese,
yogurt)
 Milk, Yogurt & Cheese
Food Group
Moderate in Nutrient Density:
2% low-fat (& low-fat products such as
yogurt, cheese, cottage cheese, chocolate
milk, sherbet, ice milk
Lowest in Nutrient Density:
whole milk (& whole milk products such as
cheese, yogurt); custard, milkshakes, ice
cream
 Milk, Yogurt & Cheese
Serving Sizes
1 cup of milk or yogurt
2 oz processed cheese food
1 1/2 oz cheddar cheese
1/2 cup ice cream or yogurt
 Fats, Oils & Sweets
Food Group
Characteristics: no servings are
provides sugar, fat, suggested because
& food energy these foods provide
few nutrients.
use sparingly.
 Fats, Oils & Sweets
Food Group
Foods high in fat: Foods high in sugar:
margarine, salad cakes, pies, cookies,
dressings, oils, doughnuts, sweet rolls,
mayonnaise, sour candy, soft drinks,
cream, cream cheese, fruit drinks, jelly,
butter, gravy, potato syrup, gelatin,
chips, chocolate bars desserts, sugar and
honey
 Reading Food Labels
Step 1
10% of calcium, fiber, protein, iron,
vitamins A & C
Step 2
greater than 10% fat or more
than 200 calories per serving
What is your score??
 Promotion of normal growth rate, organ
development, and body composition

Prevention of later disease

Obesity
Cardiac
Allergic
Cancer
 Serve as a guide for estimating nutrient
need
DRIs recently revised for specific
childhood ages (Institute of Medicine)
Much of the data are extrapolated from
adult, but increasingly more specific
Since they are group recommendations,
they include a margin of safety
 Nutrient Recommendations:
Dietary Reference Intakes (DRI)
DRI is the general term for a set of reference values used to plan and assess
nutrient intakes of healthy people, which vary by age and gender, include:
Estimated Average Requirements (EAR), expected to satisfy the needs of
50% of the people in that age group based on a review of the scientific
literature.
Recommended Dietary Allowances (RDA), the daily dietary intake level of a
nutrient considered sufficient by the Food and Nutrition Board of the Institute
of Medicine to meet the requirements of 97.5% of healthy individuals in each
life-stage and sex group. It is calculated based on the EAR and is usually
approximately 20% higher than the EAR.
Adequate Intake (AI), where no RDA has been established, but the amount
established is somewhat less firmly believed to be adequate for everyone in
the demographic group.
Tolerable upper intake levels (UL), to caution against excessive intake of
nutrients (like vitamin A) that can be harmful in large amounts. This is the
highest level of daily consumption that current data have shown to cause no
side effects in humans when used indefinitely without medical supervision.
Acceptable Macronutrient Distribution Ranges (AMDR), a range of intake
specified as a percentage of total energy intake. Used for sources of energy,
such as fats and carbohydrates.
 Vary considerably among children
Dependent on:
Basal metabolic rate
The Barker Hypothesis & Fetal Programming
Growth rate
Physical activity
Body size

Range from 1000 Kcal/d at 1 year to 2200

Kcal/d at 12 years
 Absorption of amino acids increases protein synthesis in
children (unlike adults)
The body is unable to store excess dietary amino acids
Uses them for energy production if energy intake is low
Or converts them to glucose or fat if energy intake is adequate
Daily protein requirement ranges from 12 grams at 1 year
to 35 grams at 12 years
Note that protein requirements during childhood are low
compared to newborn or teen
Growth rates are slower
Tissue synthetic rates are slower
Amino acid needs for growth decrease from 56% of total
intake at birth to 5% at 5 years
 The DRIs are largely extrapolated from infant or
adult data
Exceptions are for energy, protein & iron where
balance studies have been performed
Minerals/elements that are likely to be low in the
diet of young children
Calcium
Crucial for preteen girls (future osteopenia)

Iron
Zinc
Magnesium
 Healthy, growing children consuming a varied diet
do not need vitamin supplementation
Children at nutritional risk who may benefit from
vitamin supplementation
Those from deprived, neglectful or abusive families
Those consuming fad diets
Those with chronic disease, particularly affecting the
GI tract
Those on dietary programs for managing obesity
Those on vegetarian diets without adequate dairy
products
 Protein, energy and protein-energy
malnutrition
Endemic areas include sub-Saharan Africa
Iron deficiency
World-wide for various reasons
Intestinal blood loss (parasitic) in developing countries
Inadequate intake (cows milk) in developed countries

Vitamin A deficiency
Obesity
 Vary significantly based on gender and age
DRIs for males
13 - 15 years old: 2000 Kcal/d
16 - 18 years old: 3200 Kcal/d
DRIs for females*
13 - 15 years old: 2200 Kcal/d
16 - 18 years old: 2100 Kcal/d
add 300 Kcal for pregnancy; 450 Kcal for lactation
*
 Second peak of protein accretion during
childhood
Associated with significant growth spurt

DRIs for males

11 - 14 years (pre-growth spurt): 45 g/d
15 - 18 years (growth spurt): 59 g/d
Nutrient Gender Increment Increment Suggested
(average) (peak of growth spurt)

Calcium M 210 400 1100

F 110 240 1200 *
Iron M 0.57 1.1 10
F 0.23 0.9 13 **
Zinc M 0.27 0.50 12
F 0.18 0.31 9
All values are mg/d
* to increase bone mineral stores
* increased iron turnover due to menses
 Onset of puberty in both sexes increases:
Energy needs for increased physical activity
Protein needs for rapid skeletal growth
Calcium needs for bone mineralization
Onset of menstruation in girls increases:
Iron demand to replace blood loss and match
expanding blood volume
Calcium need to protect against later
osteopenia
 Visceral Proteins
Albumin
Normal range: 3.5-5 g/dL.
Synthesized in and catabolized by the liver
Pro: often ranked as the strongest predictor of surgical
outcomes- inverse relationship between postoperative
morbidity and mortality compared with preoperative
serum albumin levels
Con: lack of specificity due to long half-life
(approximately 20 days). Not accurate in pts with liver
disease or during inflammatory response
 Visceral proteins

Prealbumin (transthyretin) - transport protein for thyroid

hormone, synthesized by the liver and partly catabolized by the
kidneys.
Normal range:16 to 40 mg/dL; values of <16 mg/dL are associated with
malnutrition.
Pro: Shorter half life (two to three days) making it a more favorable marker
of acute change in nutritional status. A baseline prealbumin is useful as
part of the initial nutritional assessment if routine monitoring is planned.
Cons: More expensive than albumin. Levels may be increased in the
setting of renal dysfunction, corticosteroid therapy, or dehydration,
whereas physiological stress, infection, liver dysfunction, and over-
hydration can decrease prealbumin levels.
 Visceral proteins
Transferrin: acute-phase reactant and a
transport protein for iron
normal range: 200 to 360 mg/dL.
Medium half-life (8-10 days)
Smaller body pool than albumin, reflects more acute
changes.
influenced by several factors, including liver disease, fluid
status, inflammation, iron status and illness.
Cons: not studied extensively as albumin and pre-
albumin in relation to nutritional status, may indicator
more about iron metabolism
Levels decrease in the setting of severe malnutrition,
however unreliable in the assessment of mild malnutrition
 Other measures of nutrition
status
Nitrogen balance: the relationship between the amount of nitrogen
taken into the body, usually as food, and that excreted from the body in
urine and feces. Most of the body's nitrogen is incorporated into protein.
Protein ~ 16% nitrogen

Protein intake (gm)/6.25 - (UUN +4)= balance in grams

Positive value: found during periods of growth, tissue repair or pregnancy. This means that the
intake of nitrogen into the body is greater than the loss of nitrogen from the body, so there is an
increase in the total body pool of protein.
Negative value: can be associated with burns, fevers, wasting diseases and other serious injuries
and during periods of fasting. This means that the amount of nitrogen excreted from the body is
greater than the amount of nitrogen ingested.
Healthy Humans= Nitrogen Equilibrium
Cons: Complex determination of balance, measures of
losses difficult and limited utility in clinical setting
 Traditional Method: Diet
advancement
Introduction of solid food depends on the
condition of the GI tract.
Oral feeding delayed for 24-48 hours after surgery
Wait for return of bowel sounds or passage of flatus.
Start clear liquids when signs of bowel function
returns
Rationale
Clear liquid diets supply fluid and electrolytes that
require minimal digestion and little stimulation of the
GI tract
Clear liquids are intended for short-term use due
to inadequacy
 Things to Consider
For liquid diets, patients must have adequate
swallowing functions
Even patients with mild dysphagia often require
thickened liquids.
Must be specific in writing liquid diet orders for
patients with dysphagia
There is no physiological reason for solid foods not to be
introduced as soon as the GI tract is functioning and a few
liquids are being tolerated. Multiple studies show patients
can be fed a regular solid-food diet after surgery without
initiation of liquid diets.
 Diet Advancement
Advance diet to full liquids followed by solid
foods, depending on patients tolerance.
Consider the patients disease state and any
complications that may have come about since
surgery.
Ex: steroid-induced diabetes in a post-kidney
transplant patient.
 Nutrition Support
Enteral Nutrition Support

Parenteral Nutrition support

 What is enteral nutrition?
Enteral Nutrition
Also called "tube feeding," enteral nutrition is a liquid
mixture of all the needed nutrients.
Consistency is sometimes similar to a milkshake.
It is given through a tube in the stomach or small
intestine.
If oral feeding is not possible, or an extended NPO
period is anticipated, an access devise for enteral
feeding should be inserted at the time of surgery.
Feeds can meet 100% of patients needs or can be used
to supplement poor po intake.
 Indications for Enteral
Nutrition
When the GI tract is functional or partially
functional and..
Patient has inability to consume or absorb

adequate nutrients.
Patient is not meeting > 75% of needs with po

intake.
Malnourished patient expected to be unable

to eat adequately for > 5-7 days

Adequately nourished patient expected to be

unable to eat > 10 days

Contraindications to Enteral
Nutrition Support
Expected need less than 5-7 days if malnourished or 7-9
days if normally nourished
Severe acute pancreatitis
Small bowel obstruction, ileus or high output enteric
fistula distal to feeding tube
Inability to gain access
Hemodynamic instability
Need for high dose pressors/vasoactives
MAP consistently < 60 mmHg
Intractable vomiting or diarrhea
Those requiring massive fluid resuscitation
 Enteral Access Devices
Nasogastric
Nasoenteric
Gastrostomy
PEG (percutaneous endoscopic gastrostomy)
Surgical or open gastrostomy
Jejunostomy
PEJ (percutaneous endoscopic jejunostomy)
Surgical or open jejunostomy
Transgastric Jejunostomy
PEG-J (percutaneous endoscopic gastro-jejunostomy)
Surgical or open gastro-jejunostomy
Tulane Enteral Nutrition
Product Formulary
 What is parenteral nutrition?
Parenteral Nutrition
also called "total parenteral nutrition," "TPN," or
"hyperalimentation."
Defined as nutrients provided intravenously.
Components of a PN mixture include:
Protein (Amino Acids) , carboydrates (dextrose) , Fats
(Long-chain fatty acids), sterile water, electrolytes,
vitamins and trace minerals
For use in nutritionally compromised patients
when enteral nutrition is contra-indicated.
 Indications for Parenteral
Nutrition Support
Malnourished patient expected to be unable
to eat > 5-7 days AND enteral nutrition is
contraindicated
Patient failed enteral nutrition trial with
appropriate tube placement (post-pyloric)
Enteral nutrition is contraindicated or severe
GI dysfunction is present
Paralytic ileus, mesenteric ischemia, small bowel
obstruction, enteric fistula distal to enteral access
sites
 Benefits of Enteral Nutrition
over parenteral nutrition
Cost
Tube feeding cost ~ $10-20 per day
TPN cost ~ $100 or more per day!
Maintains integrity of the gut
Tube feeding preserves intestinal function; it is more
physiologic
TPN may be associated with gut atrophy
Less infection
Tube feedingvery small risk of infection and may
prevent bacterial translocation across the gut wall
TPNhigh risk/incidence of infection and sepsis
 Transitional Feedings
Parenteral to enteral feedings
Introduce a minimal amount of enteral feeding at a low
rate (30-40 ml/hr) to establish tolerance.
Decrease PN level slowly to keep nutrient levels at same
prescribed amount
As enteral rate is increased by 25-30 ml/hr increments
every 8-24 hrs, parenteral can be reduced
Discontinue PN solution if 75% of nutrient needs met by

enteral route.
Parenteral/Enteral to oral feedings
Ideally accomplished by monitoring oral intake and
concomitantly decreasing rate of nutrition support until
75% of needs are met.
Oral supplements are useful if needs not met 100% by
diet. Ex (Nepro, Glucerna, Boost, Ensure).