NUTRITION CONCEPTS AND APPLICATIONS IN MEDICINE

MALNUTRITION
and
DEMAND FOR ENERGY

July 19, 2018

• Malnutrition as an imbalance between the demand
and supply of energy to meet requirement

• methods used to measure energy requirements

– focusing on energy expenditure
• Nutrition is a demand led process

• Primarily the demand is for energy

• The requirement for energy:

– to support the synthetic activities of the body

– to fuel the metabolic processes of the body
• leading to expended energy/heat
 Energy requirements of healthy individuals
Definition by FAO/WHO/UNU 2004
is the amount of food energy needed to balance energy expenditure
in order to maintain:
– body size
– body composition ( fat and lean tissue)
– at a level of necessary and desirable physical activity
– all consistent with long-term good health.

• Includes energy for

– the optimal growth and development of children
– the deposition of tissues during pregnancy, and the secretion
of milk during lactation consistent with the good health of
mother and child.
How the demand for energy may be satisfied?
• CHO, lipids, proteins (and alcohol) provide all the
energy supplied by foods

• CHO, lipids & proteins are macronutrients

• in contrast to vitamins and minerals often referred

to as micronutrients

• Energy is NOT a nutrient

 Gross energy to metabolisable energy
Gross energy
kcal/g 1 cal = 4.18 J
CHO Fat Pro Alcohol: 7 kcal/g
4.10 9.45 5.65

Faecal energy Digestible energy

loss kcal/g
CHO Fat Pro
4.0 9.0 5.2
Atwater factors
Metabolizable energy
urinary energy
kcal/g
loss as N
CHO Fat Pro
4.0 9.0 4.0
Acceptable Macronutrient Distribution (AMD)
Range
for normal children and adults
(% of total calories)

Children Children Adult

1- 3 y 4 -18 y
CHO 45 - 65 45 - 64 45 - 65
FAT 30 - 40 25 - 35 20 - 35
PROTEIN 5 - 20 10 - 30 10 - 35

 Saturated fat < 10% to reduce cardiovascular disease

Institute of medicine (IOM), 2006

 Calculation
• If total energy intake in an adult = 2500 kcal
• fat intake is 135g and protein intake is 65g

• % Energy derived from fat =

Comments?
• 135 x 9/2500 x 100 = 49%
• High fat intake

• % energy from protein =

• 65 x 4/2500 x 100 = 10%
 Energy balance
Essential in assessment of energy requirement

• Components of energy balance:

– energy intake
– energy expenditure
– energy stores
 positive
Energy Balance
Energy Energy
intake expenditure

negative

1. Equilibrium: energy intake = energy expenditure

 eg in normal healthy adults
 maintaining weight (no change in energy stores)
 according to 1st law of thermodynamics

2. Negative energy balance: intake < expenditure

 weight loss - depleting energy stores from underfeeding or
starvation
 wasting: weight-for-length/height less than
reference
 stunting: height-for-age less than reference
• 3. Positive energy balance:
– intake > expenditure
– increase in energy stores:
• growth, pregnancy
• recovering weight loss eg from illness
• development of obesity

• Only ~10 kcal/d in excess to gain 1 lb/year

(3500kcal)
Estimated ~925 million malnourished people in the world
(WHO, 2010)

Children
• Globally, 165 million children under five are estimated to
have low length/height-for-age (stunting)
• more than 100 million have low weight-for-height (wasting)
• Undernutrition is associated with ~ 45 % of death in children
under 5 years of age
• 43 million are overweight or obese.

Adults
• obesity is a global health problem
• huge health and economic cost
Ref: National strategic and action plan for the prevention and control of non-
communicable diseases in Jamaica 2013 - 2018
Majority of children have same potential to grow: but cannot
reach genetic potential without adequate Energy and nutrients

Same age

Globally, 1 in 4 children is stunted

associated with lower adult cognition, educational attainment, and
income.
Estimating energy requirements in
healthy population
 Energy requirements of healthy individuals
Definition by FAO/WHO/UNU 2004
is the amount of food energy needed to balance energy
expenditure in order to maintain:
– body size
– body composition (fat and lean)
– at a level of necessary and desirable physical activity
– all consistent with long-term good health.

• Includes energy for

– the optimal growth and development of children
– the deposition of tissues during pregnancy, and the secretion
of milk during lactation consistent with the good health of
mother and child.
 Estimating energy requirements
• In theory energy requirements could be based on
measurement of:
– either energy intake
– or energy expenditure
– or both

• Measurement of dietary intake is usually less reliable than

measurements of energy expenditure

• WHO recommends using energy expenditure determined with

the Double Labelled Water (DLW) method and/or minute-by-
minute heart rate monitoring to assess total energy
requirements
- basis of WHO Human Energy requirements (2004)
Human energy requirements
Report of a Joint FAO/WHO/UNU
Expert Consultation, 2004

Free online
 Theoretical concept of measuring energy
expenditure
• To produce energy in the body, macronutrients are
oxidized or combusted in the presence of oxygen to
release carbon dioxide, water and heat/energy.

• The heat/ energy produced can be measured:

– directly in a whole body calorimeter
– or estimated indirectly from O2 consumption and CO2
production ( respiratory exchange)
 Techniques for measuring energy
expenditure.
Generally based on:

1. Direct calorimetry
2. Indirect calorimetry
 DIRECT CALORIMETRY

• Direct measurement of
– heat produced by a subject placed in an enclosed
structure large enough to permit moderate activity

• Limitations
– confined nature of testing conditions
– technically demanding
– high cost
– infrequently used
 INDIRECT CALORIMETRY
• Frequently used

• Indirect assessment of heat/energy

• by respiratory gas analysis:

from measuring O2 consumption and CO2
production

• Based on the fact that:

When components of the macronutrients ( glucose,
fatty acids and amino acids) are oxidized in the body
O2 is used and CO2 is produced in proportion to the
heat generated as illustrated with glucose
Concept of indirect calorimetry.1
Heat
A simple example is combustion/oxidation of glucose: energy
measured
C6H12O6 + 6O2 = 6CO2 + 6H2O + heat directly

180g 6 x 22.4 6 x 22.4 6 x 18g 2.78 MJ

liters liters

Therefore for CHO,

1 litre O2 consumption = 2.78/(6 x 22.4) = 20.8 kJ or 4.95 kcal

Similarly,
1 litre CO2 produced = 2.78/(6x22.4) = 4.95 kcal expended
 Concept of indirect calorimetry. 2
Similar equations for the combustion of fatty acids and
amino acids:-
fatty acid: 4.60 kcal/liter O2 consumed
amino acids: 4.49 kcal/liter O2 consumed
glucose: 4.95 kcal/liter O2 consumed
• The values are fairly close, so an average of 4.8 kcal/liter
O2 consumed is commonly used to calculate Energy
production of mixed foods from O2 consumption.

• Similar application for CO2 production

Weir’s eqn- most widely used to calculate energy
expenditure (EE)

– EE (kJ) = 16.489 VO2 (l) + 4.628 VCO2 (l) - 9.079N (g)

(VO2 = oxygen consumption, VCO2 = CO2 production, N= Urinary nitrogen)

Modified Weir’s eqn

• If urinary N is not measured, but it is assumed that
protein oxidation is 15 % of TEE, the formula becomes
– EE (kJ) = 16.318 VO2 (l) + 4.602VCO2 (l)
 Respiratory quotient (RQ)
= moles CO2 expired/ moles O2 consumed

 depends on nutrient mixture

 CHO = 1
 FAT = 0.7
 PROTEIN = 0.8
 Typical western diet = 0.87
 COMPONENTS OF TOTAL ENERGY EXPENDITURE
Components of total energy expenditure (TEE):
– BMR + activity EE + diet induced thermogenesis (DIT)

Basal Metabolic Rate (BMR) or Basal Energy Expenditure (BEE)

– It is the minimum level of energy expended by the body to

sustain life in the awake state
1. membrane function, eg ionic movement
2. substrate turnover, eg protein turnover
3. mechanical work

– Usually the largest component of TEE (~45 -70%)

– relatively constant within a normal individual over time
– determined mainly by the individual’s age, gender, body
size and body composition
 ACTIVITY

• Physical activity accounts for ~15 to 30 % of

TEE in most individuals

• Most variable component of energy

expenditure
 Diet induced thermogenesis

Energy expended to digest, metabolize, convert and

store ingested macronutrients
- extends over at least 5 h.

~ 10% of the BMR over a 24-hour period in

individuals eating a mixed diet
So, methods for measuring energy expenditure
may be based on:
• measuring components of energy
expenditure
• or direct measure of total energy
expenditure
 Equipment for INDIRECT CALORIMETRY

• Respiratory gas analysis can be achieved

– over short measurement periods at rest
– during exercise using a face mask, mouthpiece or canopy
– or over longer periods using large respiration chamber

Limitations
– Hyperventilation may occur in subjects who are not well
adapted to a mouthpiece
– Difficult to obtain an airtight seal with mouthpiece

– Environment in respiration chamber is artificial

Respiration chamber- attached to O2 and CO2 sensors
 Measurement of Basal Metabolic Rate
(BMR)
• BMR is measured under standardized conditions-
after;
– ~12h fast
– while resting comfortably, supine, awake and
motionless
– in a thermoneutral quiet environment.

• Difficulty in achieving BMR under most

measurement conditions, so RMR or REE is
frequently measured using the same conditions
(~ 3% difference)
 Equipment for INDIRECT CALORIMETRY contd
• The ventilated canopy system
 BMR PREDICTIVE EQUATIONS #1
Harris-Benedict ( kcal/d)
• Men
– BMR = 66 + (13.7 x weight in kg) + ( 5 x height in cm ) - (6.76 x
age in years )

• Women
– BMR = 655 + (9.6 x weight in kg) + (1.8 x height in cm) - (4.7 x
age in years)

• Other equations:
– Schofield for adults
– Cunningham for adults
– FAO/WHO/UNU 1985 for children and adults
 Change in Basal energy expenditure

Large increase in hypermetabolic states

 Other hypermetabolic states
• Eg
– Hyperthyroidism: weight loss
– HBSS
 MEASURMENT OF FREE LIVING ACTIVITY ENERGY
EXPENDITURE

METHODS
1. Heart rate recording monitor
2. Various motion detector devices - accelerometers
3. Activity diary with known energy cost of activity
4. Derived from estimates of TEE , RMR & TEF
Physical activity energy = TEE- (RMR + TEF)
Most accurate when TEE is measured by doubly labelled
water
 HEART RATE RECORDING
• Usually based on correlation between heart rate
and oxygen consumption during moderate to heavy
exercise

• The correlation is poor at low levels of physical

activity

• When used to estimate energy requirements,

individual calibrations of the relationship
between heart rate and oxygen consumption
are done.
 Total Energy Expenditure using DOUBLY LABELLED
WATER (DLW): isotopic technique

• Most substantial advance in the measurement of Total

Energy Expenditure in humans living under their
habitual free living conditions (gold standard)
– using stable isotopes to trace water kinetics and to determine
CO2 production- how?

• A bolus oral dose of two isotopic water is given:

1. 2H2O – water isotopically labeled with 2H (deuterium)
2. H218O - water isotopically labeled with 18O

• Urine or saliva or plasma samples are collected over

about 7 – 14 days
• for isotopic analysis using Mass-spectrometry
• the rates of elimination of the isotopes are calculated
 DOUBLY LABELLED WATER (DLW)
isotopic technique

• the rate of CO2 production is estimated from the kinetics of

water turnover in the body

• Hydrogen in body water is eliminated only as water.

• Oxygen in body water is eliminated as both water and CO2

– oxygen in water is in rapid and complete equilibrium with
oxygen in CO2 through the enzyme carbonic anhydrase
• The difference between the elimination rates of the two isotopes
represents CO2 production.
 DOUBLY LABELLED WATER (DLW)
isotopic technique

• CO2 production is the result of fat, CHO and protein oxidation ie

index of energy expenditure

• is equated to energy expenditure using indirect calorimetry

formulae as discussed previously
 DOUBLY LABELLED WATER
Advantages Disadvantages
Non invasive, unobtrusive Limited availability

Performed under free living Expensive

conditions
Reliance on Isotope ratio
Performed over several days mass- spectrometer
Can be used to derive activity
energy expenditure ( best estimate)

TEE = REE + Activity EE + TEF

Physical activity level- PAL
PAL = TEE/REE

• Used in classification of lifestyle:

– Sedentary or light activity lifestyle: 1.40-1.69
– Active or moderately active lifestyle: 1.70-1.99
– Vigorous or vigorously active lifestyle: 2.00-2.40

• May also be used to estimate avg energy

requirement depending on life style
– If total energy expenditure not available
 ENERGY REQUIREMENT: CALCULATION eg. 1
Energy requirement of a male engaged in heavy work: age
35 y, wt = 65 kg, height = 1.72m, BMI 22
– BMR = 68 kcal/h (measured or derived)
PAR hours kcal (RMR x PAR x hrs)

In bed 1.0 8 544

Occupational activities 3.8 8 2067
Discretional activities : 3.0 1 204
leisure
For residual time: 1.4 7 666
Bathing, dressing etc
Total 3481
PAR: physical activity ratio expressed as multiple of RMR
How might pathology alter the demand for energy ?
eg in severe undernutrition in adult or child
Nutritional support: severe undernutrition
• A main objective of nutritional support
– is to ensure that all interventions are within the
functional capacity of the individual ie metabolic
demand
– to prevent further metabolic stress on the brittle
homeostatic system

• Possible danger of over enthusiastic nutrition support

– can project an individual from a situation of just
being able to cope to one of being unable to cope
 Nutritional support: severe undernutrition
• During acute resuscitation, problems such:
– infection, dehydration, oedema, electrolyte and
micronutrient deficiencies are treated

• During this time a diet providing energy and protein

enough to maintain body weight is given
– ie within functional capacity & matching demand
– 80 -100 kcal/kg/d (WHO, 2007)
– ~0.7 -1 g protein/kg/d
Nutritional support: severe undernutrition
Catch-up growth
• When the acute problems have been treated and
appetite and affect have returned, a high energy diet
may be given for rapid catch-up growth (RCUG)

• Protein-energy-ratio (PER) important for optimum

tissue deposition during RCUG
– PER < 7 - deposition of more fat than lean tissue
– usually ~11
– because a greater increase in protein than for
energy is required to make desirable body
composition at rapid rates of weight gain
– Recommended energy intake for normal healthy
individuals are published by various export groups by
age, sex and activity level such as:
• RDA (Recommended Daily Allowance) by WHO
• DRI (Dietary Reference Intake) by Institute of Medicine
(IOM)
• Reviewed periodically

– References:
• Human energy requirements , UNU/WHO/FAO, 2004
• Dietary Reference Intakes for Energy, Carbohydrate, Fiber,
Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids
(Macronutrients), IOM, 2005
Human energy requirements
Report of a Joint FAO/WHO/UNU
Expert Consultation, 2004
 Role of protein quantity and quality in
protein/energy relationship
 Dietary Protein Quality is a measure of the:
 availability of the essential amino acids
 and utilization of amino acids
 therefore depends on aa composition & digestibility

• Essential amino acids are not made in the body and must be
provided in the diet: val, ise, leu, met, phe, lys, thr, trp in
adults. Plus arg in children

• Body cannot synthesize adequate lean tissue with insufficient

protein
– dietary energy partition to make adipose tissue
– reduced bone growth and stunting
END
Additional slides
 PRIMARY MALNUTRITION
Inadequate nutrition (energy and nutrients) leading to wasting & stunting
• significant wasting and/or oedema
– severe: weight-for-length/height < -3SD or MUAC < 110 mm in
children 6 to 59 months of age
– moderate: between -2SD and -3SD
– Mild: between -1SD and -2SD
• often with concurrent infective illness
• with or without stunting
• Similar SD categories for stunting using length or height-for-age

• Ref: WHO growth chart- free software online, most recent

• NB: Use length if under 2 years of age and height if older
 BMR PREDICTIVE EQUATION #2
Schofield equation for adults

Males (kcal/d):
• 10 - 17 years BMR = 17.7 x W + 657
• 18 - 29 years BMR = 15.1 x W + 692
• 30 - 59 years BMR = 11.5 x W + 873

Women (kcal/d):
• 10 - 17 years BMR = 13.4 x W + 692
• 18 - 29 years BMR = 14.8 x W + 487
• 30 - 59 years BMR = 8.3 x W + 846

• W = body weight in kg
 BMR PREDICTIVE EQUATIONS # 3
Energy & protein requirements FAO/WHO/UNU 1985

Age range (yrs) BMR (kcal/d) BMR (kcal/d)

Males Females

0-3 60.9 W - 54 61.0 W - 51

3 - 10 22.7 W + 495 22.5 W + 499
10 - 18 17.5 W + 651 12.2 W + 746
18 -30 15.3 W + 679 14.7 W + 496
30 - 60 11.6 W + 879 8.7 W + 829
> 60 13.5 W + 487 10.5 W + 596
W = body wt in
kg
 PREGNANCY
Dietary intake during pregnancy must provide the
energy that will ensure:

• full-term delivery of a healthy newborn baby of adequate

size and appropriate body composition

• by a woman whose weight, body composition and physical

activity level are consistent with long-term good health and
well-being

• ideally a woman should enter pregnancy at a normal weight

and with good nutritional status.
The energy cost of pregnancy is determined by
the energy needed:

• for maternal gestational weight gain

– which is associated with protein and fat
accretion in maternal, foetal and placental
tissues

• and by the increase in energy expenditure

associated with basal metabolism and
physical activity
• Muscle and the major organs of the body predominantly
account for RMR
– fat free mass (FFM) explains 60 – 80% of interindividual variation

– depends on composition of FFM

eg in an adult skeletal muscle: 22- 36% of RMR, brain: 20 -24%)

• RMR:
– falls with age
– is higher in males compared to females
– is higher in more active individuals than inactive
– affected by thyroid hormones (high levels increase metabolic
rate and vice versa)

• A portion of interindividual variation has been ascribed to genetic

factors- but specific source not identified
 Effect on illness on energy requirements

Overall metabolic demands are not always elevated

BMR PA

Elevated demand: Raised BMR with illness PA

Low
Reduced demand : Raised BMR with illness
PA