NFS 444 Lecture Notes - Lecture 10: Ketone Bodies, High-Protein Diet, Kwashiorkor

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6 Feb 2017
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NFS 444 (Pharmacy) - Exam 1 Review Sheet
Starvation/Malnutrition
1. Indicators of malnutrition (IBW, %IBW, %ABW, %UBW, adjusted IBW, %wt change over time)
a. Ideal Body Weight (IBW)
i. Hamwi Method
1. Women: 100lbs. + 5lbs. for every inch over 5 feet
2. Men: 106lbs. + 6lbs. for every inch over 5 feet
b. Percent Ideal Body Weight (% IBW)
i. (Actual weight / IBW) x 100
ii. Normal is 90-109%
c. Percent Usual Body Weight (% UBW)
i. (Actual weight / UBW) x 100
ii. Important to ask patient if they were trying to lose weight!!
d. Degree of malnutrition
e. Adjusted Ideal Body Weight
i. IBW + (0.25 x (ABW IBW))
f. Percent Weight Change
i. (Usual Body Weight Current Body Weight) / Usual Body Weight, Then x 100
ii. Significant Values
1. 1-2% in 1 week
2. 5% in 1 month
3. 7.5% in 3 months
4. 10% in 6 months
2. Starvation related malnutrition
a. Sources of energy during starvation
i. Fatty acids main source of energy during starvation!!
ii. Brain and neural tissue can only use glucose and ketone bodies for energy
iii. A. When a person overeats (feasting): When a person eats in excess of energy
needs, the body stores a small amount of glycogen and much larger quantities
of fat. Glucose is a major energy source. B. When a person draws on stores
(fasting): When nutrients from a meal are no longer available to provide energy
(about 2 to 3 hours after a meal), the body draws on its glycogen and fat stores
for energy. Fatty acid is major energy source C. If the fast continues beyond
glycogen depletion: As glycogen stores dwindle (after about 24 hours of
starvation), the body begins to break down its protein (muscle and lean tissue)
to amino acids to synthesize glucose needed for brain and nervous system
energy. In addition, the liver converts fats to ketone bodies, which serve as the
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alternative energy source of the brain, thus slowing the breakdown of body
protein
b. Purpose of the Ancel Keys Minnesota Study
i. 36 people participated in this study that was designed to determine the
physiological and psychological effects of severe and prolonged dietary
restriction and the effectiveness of dietary rehabilitation strategies.
ii. It was recognized early in 1944 (WWII) that millions of people were in grave
danger of mass famine as a result of the conflict, and information was needed
regarding the effects of semi-starvationand the impact of various
rehabilitation strategiesif postwar relief efforts were to be effective.
iii. These subjects were anti-war, so they decided to help in another way through
this study.
c. Know what ketosis is and consequences of it
i. When the rai’s main energy source comes from ketone bodies synthesized in
the liver from fatty acids (This occurs when glucose levels are low)
ii. Ketones serve as an alternative energy source for the brain and neural tissue
other than glucose
iii. Causes loss of appetite in starving people
d. Know clinical signs of starvation and why they occur
i. Decreased metabolic rate
ii. Decreased physical activity
iii. Mobilization of adipose tissue
iv. Preservation of LBM
v. Loss of electrolytes (intracellular K+, Mg, phosphate, water soluble vitamins,
calcium from bone, sodium and water)
vi. Weight loss (lack of caloric intake)
vii. Loss of body fat and muscle (being broken down for gluconeogenesis,
production of ketones, and basal energy expenditures)
viii. Growth failure in children
1. Wasting- low body weight
2. Stunting- Low height
ix. Amenorrhea in women
1. Need at least 10-12% body fat in order to menstruate
x. Decreased strength and fatigue due to loss of muscle
xi. Delayed wound healing
xii. Impaired immune response
xiii. Decreased organ function (risk of organ failure- often fatal!)
xiv. GI tract, heart, and kidney- loss of function and muscle surrounding organs
xv. Respiration
1. Decreased vital capacity (the greatest volume of air that can be expelled
from the lungs after taking the deepest possible breath)
2. Increased risk of pneumonia
xvi. Psychological symptoms
e. Gluconeogenesis
i. The synthesis of glucose from non-carbohydrate precursors, such as fatty acids
and amino acids (occurs in liver)
ii. Occurs about 24 hours after fasting when all glycogen stores in the liver have
been used up
iii. Mainly amino acids are converted to glucose (gluconeogenesis) and fatty acids
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are converted to ketone bodies that can also serve as energy for the brain in
place of glucose (ketosis).
f. Difference between kwashiorkor and Marasmus
i. Kwashiorkor is a form of malnutrition that is caused due to insufficient intake of
proteins, whereas Marasmus is caused due to insufficient intake of proteins, fats
and carbohydrates.
ii. Kwashiorkor more common in children
iii. With Kwashiorkor, person could be getting sufficient calories per day, but not
enough protein
iv. Symptoms of Marasmus much more obvious than those of Kwashiorkor
g. Refeeding syndrome (what is it? Which labs values are a concern/ should be
monitored?)
i. A metabolic complication that occurs when nutritional support is given to
severely malnourished patients. Metabolism shifts from a catabolic (building)
state to an anabolic (breaking down) state. Insulin is released in response to
carbohydrate intake, triggering cellular uptake of potassium, magnesium, and
phosphate. This leaves dangerously low levels in the blood and can cause
hypophosphatemia, hypokalemia, and hypomagnesaemia. Patients should start
TPN more cautiously than usual and be monitored carefully and frequently.
3. Know what makes up body cell mass
a. Body Cell Mass (BCM)= skeletal muscle (60%) and organs (40%)
i. Loss of about 50% of BCM is usually fatal
4. How can diet help minimize loss of BCM
a. Normally, loss of BCM is not an issue because we (in first-world countries) eat enough
calories so that our bodies do not require amino acids from our BCM as a source of
energy.
b. However, in individuals experiencing starvation, the following applies (if dietary intake is
an option)
i. Higher protein intake decreases loss of BCM
1. This is because the amino acids from the protein being ingested can
serve as an energy source instead of the body breaking down skeletal
muscle for energy.
ii. CHO intake decreases loss of BCM
1. Carbs are converted to glucose for energy, which is the main reason
BCM is being lost in the first place.
Nutrition Assessment
1. Screening, Steps of Nutrition Care Process
a. Screening
i. Identify at-risk individuals who may require a more comprehensive nutrition
assessment
ii. Usually done by nurses because they are the first health care professional to see
the patient
1. Although the criteria to determine at-risk individuals is developed by
dieticians
iii. Ask simple questions about their nutrition (no calculation questions)
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