Energy balanceNutritional Screening  and Assessment            Lubos Sobotka Charles University - Medical Faculty         ...
Learning Objectives To the principles of measurement of energy expenditure To now how to diagnose a risk of malnutrition T...
Flow of energy in biosphere                                                       H2O + CO2                               ...
Energy expenditure  FOOD                         O2             CHO                                   CO2             Fat ...
Components of energy expenditure        -adult person-      Activity induced energy      Is the most variable      expendi...
Energy expenditure measurement            Direct calorimetry  Measurement of heat produced during  energy processes       ...
Direct calorimetry          Whole body heat productionSpecial chambersdifference in heat coming into and out of thechamber...
Indirect calorimetry  Measurement of O2 consumption                         VO2  production             VcO2, cCO2        ...
Indirect calorimetry                                                   flow                 CO2-analyser                  ...
Ventilated hood - canopy
Indirect calorimetryVO2 = 0.829 CHO + 2.02 Fat + 6.04 NitrogenVCO2 = 0.829 CHO + 1.43 Fat + 4.84 NitrogenSubstrate oxidati...
Indirect calorimetryEnergy expenditure can be calculated both from VO2 andVCO2:Calculation from VO2 and VCO2:EE = 3.95 VO2...
Relationship between REE and RQ[REE calculation based on VO2 or on VCO2]                            120,0                 ...
Measurement of EE using doubly labeled water                                                2H 18 O                       ...
Relationship between heart rate and energy                expenditure                     12,00                     10,00 ...
Relationship between heart rate and energy          expenditure –whole group                         14                   ...
Relationship between heart rate and energy       expenditure –individual patients                        18               ...
Harris-Benedict equationsThe most common approach to predict resting energy expenditureMale:REE = 66.5 + (13.8 x weight) +...
The theoretical reserves of a 74 kg                manBody substrate      Substrate weight   Energy content               ...
Prevalence of undernutrition• Ambulatory outpatients       1-15%• Institutionalized patients   25-60%• Hospitalized patien...
Assessment ofNutritional status  1. Screening 2. Assessment
ESPEN Guidelines   for Nutrition Screening • All patients should be screened on admission to the   hospital • If the patie...
Nutritional screeningIs a tool to rapidly and simplyevaluate whether the patient isat risk to be or to becomemalnourished
Nutritional screeningHistory:• Weight loss over time• Anorexia, nausea• Food intakeFirst measurements:• Body weight• Heigh...
Screening tools  • Nutritional Risk Index1 - biochemical  • Subjective global assessment2  • Malnutrition Universal Screen...
Nutritional risk screening  Subjective global assessment (SGA)I Patient‘s history   (weight loss, change in dietary intake...
ESPEN guidelines for nutrition screening                     2002Part 1         Kondrup J et al. ESPEN guidelines for nutr...
Part 2         Kondrup J et al. ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003
Nutritional AssessmentIs the actual measurement ofnutritional state and has to be donein patients that are considered to b...
Normal body composition• Normal body cell mass (BCM) is the major  determinant of an adequate nutritional state:  – Living...
What can be measured?• Fat body mass     Body fat percentage      Fat distribution (visceral fat)• Lean body mass     Wate...
The two compartments model           Fat mass       Fat free body mass
The four compartments model             Fat mass       Fat free body mass           • body cell mass        • extra-cellul...
Body composition changes in       normal adult malesAge (years)   Muscle (kg)   Body fat (kg)  20-29           24         ...
Underwater weighing               Fat mass               Fat-free               mass
Dilution method – deuterium/bromide                        Deuterium –TBW                        Bromide-ECV
Anthropometry Muscle-mass  Fat-mass
Anthropometry
Anthropometric measurement• Validation only partially performed• Large inter-individual variability• Good intra-individual...
Creatinine excretion in urine• Creatinine excretion correlates with  lean body mass and body weight• 18-20 kg of muscle pr...
Norm values for urinary creatinine        exretion/mg/24h  Urinary creatinine (mg/24h)                                Norm...
Urinary creatinine excretion          is influenced by:• Decreasing renal function; oliguric renal  insufficiency• No meat...
Body fat distributionand waist circumference              • Measured at the mid-point                between the ileac cre...
Bioelectrical impedance analysis (BIA)• BIA allows the determination of  - Fat-free mass and  - Total body water
ESPEN - GUIDELINESBioelectrical impedance analysis                      Fat-free mass and                      Total body ...
Bioelectrical impedance           analysis (BIA)• BIA allows the determination of  - FFM on the basis of TBW measurement• ...
Dual energy X-rayabsorptiometry (DEXA)              • Three-compartment                model              • Fat mass, free...
MRI or CT scan                 • Fat mass
Creatinine excretion in urine• Creatinine excretion correlates with  lean body mass and body weight• 18-20 kg of muscle pr...
Muscle strength
Muscle strength• Is a good predictor of outcome:  – In chronic situations:    • Aging    • Organ failure (renal failure, C...
SummaryPractical methods for measuring: Fat mass• Subcutaneous   skin folds measurements• DEXA• MRI, CT scan• BIA
Summary  Practical methods formeasuring: Fat-free mass • DEXA • BIA • (Underwater weighing)
Summary      Practical methods for    measuring: Body cell mass• (Total body potassium)• (Nitrogen neutron activation)
Summary Practical methods formeasuring: Muscle mass• Mid-arm circumference• Creatinine height index• Urinary 3-Methylhisti...
SummaryPractical methods formeasuring: Body-water • Total body water   (- Isotopic labeling of water)   - BIA • Extracellu...
SummaryPractical methods for measuring:           Bone mass  • DEXA  • Total body calcium-measured     by isotopes methods
Inflammatory and disease         activityDisease always includes inflammatoryactivity• Clinical evaluation  - Pre-existing...
Serum proteins• Albumin              (T½):      20 days• Transferrin           (T½):     8-10 days• Transthyretin        (...
Wound healing is dependent of       endogenous substrates  Undernutrition                       poor wound healing        ...
Complicated surgical wound
Complicated operation wound                        Granulation                        stimulation
Complex treatment           Wound before the            last operation
A sterile gauze poured byhyaluronan-iodine complex
Infectious complications      and albumin                  Kudsk et al, JPEN 2003
How to measure food intake• Bomb calorimetry of food before and after  meal (double plate method)• Weighing of food before...
Quarter plate method                • Standard meal                •   2000 kcal                •   60 g protein          ...
Calculate energy and protein intake– he eats ¼ of servings                         • Standard meal                        ...
Calculate energy and protein intake – he eats ¼ of servings                          • Standard meal                      ...
Calculate daily energy balance• Energy balance EB:  EB = EI – TEE  EB = 500 – 1800 = -1300 kcal/day
Calculate daily need of supplements• Energy deficit: 1300 kcal/day• Protein deficit: 30.4 g dayStandard supplement (sippin...
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  1. 1. Energy balanceNutritional Screening and Assessment Lubos Sobotka Charles University - Medical Faculty Hradec Kralove Czech Republic
  2. 2. 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
  3. 3. Flow of energy in biosphere H2O + CO2 +N O2 O2 ATP ph CHO ot os Fat ynH2O + CO2 th Proteins es is N
  4. 4. Energy expenditure FOOD O2 CHO CO2 Fat H 2O Proteins Nitrogen Heat BODYRESERVES Total energy expenditure - TEE resting energy expenditure - REE diet induced energy expenditure - DEE activity induced energy expenditure - AEE
  5. 5. Components of energy expenditure -adult person- Activity induced energy Is the most variable expenditure ∼ 60-70% component of TEE Dependent on physical activity An postprandial increase in Diet induced energy EE above basal fasting level expenditure ∼ 10% Lasts for several hours after meal Maintaining cell membrane ion gradients Constant protein synthesis and breakdown Resting energy expenditure Amino acid metabolism ∼ 60-70% Glycogen synthesis and breakdown Fatty acids cycle Gluconeogenesis Energy for breathing and heart function
  6. 6. Energy expenditure measurement Direct calorimetry Measurement of heat produced during energy processes Indirect calorimetry Measurement: O2 consumption VO2 production
  7. 7. Direct calorimetry Whole body heat productionSpecial chambersdifference in heat coming into and out of thechamber V T1 V T2 EE ∼ ∆Q = V (T2 – T1)
  8. 8. Indirect calorimetry Measurement of O2 consumption VO2 production VcO2, cCO2 V cO2, cCO2EE ∼ VO2 consumption and VCO2 production
  9. 9. Indirect calorimetry flow CO2-analyser respiratory air ventilated hood or gasmeter O 2-analyser respiration chamberoutdoor air ² CO 2 ²O2outdoor air Westerterp K, Schols A Basics in Clinical Nutrition, 2004
  10. 10. Ventilated hood - canopy
  11. 11. Indirect calorimetryVO2 = 0.829 CHO + 2.02 Fat + 6.04 NitrogenVCO2 = 0.829 CHO + 1.43 Fat + 4.84 NitrogenSubstrate oxidation:CHO = 4.59 VCO2 – 3.25 VO2 – 3.68 NitrogenFat = 1.69 VO2 – 1.69 VCO2 – 1.72 NitrogenProtein = 6.25 NitrogenEnergy expenditure:EE = 3.87 VO2 + 1.19 VCO2 – 5.99 N
  12. 12. Indirect calorimetryEnergy expenditure can be calculated both from VO2 andVCO2:Calculation from VO2 and VCO2:EE = 3.95 VO2 + 1.11 VCO2Calculation from VO2:EE = VO2 (3.95 + 1.11 RQ) – moderately dependent on RQCalculation from VCO2:EE = VCO2 (1.11 + 3.95/RQ) – Highly dependent on RQDoubly labeled water, labeled bicarbonate
  13. 13. Relationship between REE and RQ[REE calculation based on VO2 or on VCO2] 120,0 115,0 Difference in REE [%] 110,0 105,0 VCO2 100,0 VO2 95,0 VO2 a VCO2 90,0 85,0 80,0 0,7 0,75 0,8 0,85 0,9 0,95 1 RQ REE calculated from VCO2 is more dependent on RQ (possible mistake 15%) then if calculated from VO2 (possible mistake 4%)
  14. 14. Measurement of EE using doubly labeled water 2H 18 O 2 2H 18 O Labels Labels water and water pool bicarbonate pools 2HHO H 2 18 O CO 18 O K2 = rH K18 = r CO + rH 2O 2 2O K18 - K2 = r CO 2Principle of the doubly labelled water (2H218O) method for the measurement ofcarbon 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 afunction of rCO2 and rH2O. Westerterp K, Schols A Basics in Clinical Nutrition, 2004
  15. 15. Relationship between heart rate and energy expenditure 12,00 10,00 8,00Energy expenditure [kcal/min.] 6,00 4,00 2,00 0,00 40 50 60 70 80 90 100 110 120 130 140 Heart rate [b/min]
  16. 16. Relationship between heart rate and energy expenditure –whole group 14 12 10 Energy expenditure 8 [cal/min.] 6 4 2 0 75 95 115 135 155 175 Heart rate [b/min]
  17. 17. Relationship between heart rate and energy expenditure –individual patients 18 16 14 12 Energy expenditure [cal/min.] 10 8 6 4 2 0 95 105 115 125 135 145 155 Heart rate [b/min]
  18. 18. Harris-Benedict equationsThe most common approach to predict resting energy expenditureMale: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)
  19. 19. The theoretical reserves of a 74 kg manBody substrate Substrate weight Energy content ( kg ) ( kcal )Fat 15 141.000Protein 12 48.000Glycogen (muscle) 0.5 2000Glycogen (liver) 0.2 800Total 191.800
  20. 20. Prevalence of undernutrition• Ambulatory outpatients 1-15%• Institutionalized patients 25-60%• Hospitalized patients 35-65% Omran et al, Nutrition 2000• These rates depend on how malnutrition is defined
  21. 21. Assessment ofNutritional status 1. Screening 2. Assessment
  22. 22. 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 madeNutrition Screening 2002, Clin Nutr 2003www.espen.org → Education → Guidelines
  23. 23. Nutritional screeningIs a tool to rapidly and simplyevaluate whether the patient isat risk to be or to becomemalnourished
  24. 24. Nutritional screeningHistory:• Weight loss over time• Anorexia, nausea• Food intakeFirst measurements:• Body weight• Height BMI (kg/m2)
  25. 25. Screening tools • Nutritional Risk Index1 - biochemical • Subjective global assessment2 • Malnutrition Universal Screening Tool (MUST)3 • Nutritional Risk Screening (NRS 2002)4 • MNA (elderly)51 Veterans Affairs, New Engl J Med 1991 4 Kondrup et al, Clin Nutr 20032 Detsky et al, JPEN, 1984 5 Vellas et al, Nutrition 19993 BAPEN
  26. 26. Nutritional risk screening Subjective global assessment (SGA)I Patient‘s history (weight loss, change in dietary intake, gi-symptoms, functional capacity)II Physical examination (muscles, subcutaneous fat, edema, ascites)Clinician‘s overall judgment • good nutritional status • moderate malnutrition • severe malnutrition Detsky et al, JPEN, 1984
  27. 27. ESPEN guidelines for nutrition screening 2002Part 1 Kondrup J et al. ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003
  28. 28. Part 2 Kondrup J et al. ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003
  29. 29. Nutritional AssessmentIs the actual measurement ofnutritional 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
  30. 30. 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
  31. 31. What can be measured?• Fat body mass Body fat percentage Fat distribution (visceral fat)• Lean body mass Water: extra and intracellular Body cell mass Muscle mass Bone
  32. 32. The two compartments model Fat mass Fat free body mass
  33. 33. The four compartments model Fat mass Fat free body mass • body cell mass • extra-cellular water • bone
  34. 34. Body composition changes in normal adult malesAge (years) Muscle (kg) Body fat (kg) 20-29 24 15 40-49 20 19 60-69 17 23 70-79 13 25 Young 1992
  35. 35. Underwater weighing Fat mass Fat-free mass
  36. 36. Dilution method – deuterium/bromide Deuterium –TBW Bromide-ECV
  37. 37. Anthropometry Muscle-mass Fat-mass
  38. 38. Anthropometry
  39. 39. Anthropometric measurement• Validation only partially performed• Large inter-individual variability• Good intra-individual variability if the investigator is properly trained
  40. 40. 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)
  41. 41. Norm values for urinary creatinine exretion/mg/24h Urinary creatinine (mg/24h) Norm/men Norm/women Height (cm)
  42. 42. 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
  43. 43. 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
  44. 44. Bioelectrical impedance analysis (BIA)• BIA allows the determination of - Fat-free mass and - Total body water
  45. 45. ESPEN - GUIDELINESBioelectrical impedance analysis Fat-free mass and Total body water1) Review of principles & methods. Clin Nutr 2004; 23: 1226-12432) Utilisation in clinical practice. Clin Nutr 2004; 23: 1430-1453www.espen.org/education
  46. 46. 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)
  47. 47. Dual energy X-rayabsorptiometry (DEXA) • Three-compartment model • Fat mass, free-fat mass and bone • State of hydration may affect results
  48. 48. MRI or CT scan • Fat mass
  49. 49. 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)
  50. 50. Muscle strength
  51. 51. 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)
  52. 52. SummaryPractical methods for measuring: Fat mass• Subcutaneous skin folds measurements• DEXA• MRI, CT scan• BIA
  53. 53. Summary Practical methods formeasuring: Fat-free mass • DEXA • BIA • (Underwater weighing)
  54. 54. Summary Practical methods for measuring: Body cell mass• (Total body potassium)• (Nitrogen neutron activation)
  55. 55. Summary Practical methods formeasuring: Muscle mass• Mid-arm circumference• Creatinine height index• Urinary 3-Methylhistidine
  56. 56. SummaryPractical methods formeasuring: Body-water • Total body water (- Isotopic labeling of water) - BIA • Extracellular water (- Bromide space)
  57. 57. SummaryPractical methods for measuring: Bone mass • DEXA • Total body calcium-measured by isotopes methods
  58. 58. Inflammatory and disease activityDisease 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 not suitable for the individual patient
  59. 59. Serum proteins• Albumin (T½): 20 days• Transferrin (T½): 8-10 days• Transthyretin (T½): 2-3 days (Prealbumin)• Retinol-binding protein (T½): ∼ 12 h
  60. 60. Wound healing is dependent of endogenous substrates Undernutrition poor wound healing (dehiscence, infections)Loss body cell mass Deficit endogenoussubstrates for wound healing.
  61. 61. Complicated surgical wound
  62. 62. Complicated operation wound Granulation stimulation
  63. 63. Complex treatment Wound before the last operation
  64. 64. A sterile gauze poured byhyaluronan-iodine complex
  65. 65. Infectious complications and albumin Kudsk et al, JPEN 2003
  66. 66. 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
  67. 67. Quarter plate method • Standard meal • 2000 kcal • 60 g protein • 290 g CHO • 70 g fat
  68. 68. Calculate energy and protein intake– he eats ¼ of servings • Standard meal • 2000 kcal • 70 g protein • 280 g CHO • 70 g fat
  69. 69. 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
  70. 70. Calculate daily energy balance• Energy balance EB: EB = EI – TEE EB = 500 – 1800 = -1300 kcal/day
  71. 71. Calculate daily need of supplements• Energy deficit: 1300 kcal/day• Protein deficit: 30.4 g dayStandard supplement (sipping)= 150 kcal & 6 g Prot/100 mlRecommendation= 1000 ml of standard nutrition (e.g. sipping)
  72. 72. Thank you!

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