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. Basic Care .
Wound Care .
Diabetic Care
.
Incontinence Care
.
Infusion Care
Clinical Nutrition 1

Basics of nutrition
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/1/96
B|BRAUN
OPM
.
Nutrition Care
.
Stoma Care
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. Basic Care .
Wound Care .
Diabetic Care
.
Incontinence Care
.
Infusion Care
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Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/2/96
B|BRAUN
OPM
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Nutrition Care
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Stoma Care
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. Basic Care .
Wound Care .
Diabetic Care
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Incontinence Care
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Infusion Care
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Nutrition Care
Significance of Nutrition
energy
well-being
body mass
health
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/3/96
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Energy Transfer
nutrients
O2
ATP
NH3
chemical energy transfer
CO2
 mechanical energy
 muscles
H 2O
 osmotic energy
 transport of substances
 chemical energy
 biosynthesis, reactions
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/4/96
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Energy Units
1 kJoule:
quantity of energy needed to move 1 kg 1 m forward by the
power of 1 Newton (1 kJ = 0,24 kcal)
1 kcal:
quantity of energy needed to warm 1 kg water from
14,5 up to 15,5 °C (1 kcal = 4,186 kJ)
Energy density of nutrients
carbohydrates
fat
protein
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2003-01-09/5/96
kJ/g
4
17
9
alcohol
Clinical Nutrition1/OPM Germany/Stand 02
kcal/g
38
4
17
7
29
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Energy Requirement
total metabolism
= basal metabolism + activity metabolism
basal metabolism = energy required in the state of complete resting
(fasting  12 h) to maintain body functions
activity metabolism
metabolic
= energy required in addition to basal
rate obligat for
 musculation
 digestion and metabolism
 cellular reactions
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/6/96
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Determination of Energy Requirement
25 - 35 kcal/kg body weight
basal metabolic rate (BMR) in kcal according to Harris-Benedict (1919)
f = 655,1 + 9,56 x body weight (kg) + 1,85 x height (cm) - 4,7 x age (years)
m = 66,5 + 13,75 x body weight (kg) + 5 x height (cm) - 6,8 x age (years)p
female (f), male (m)
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/7/96
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Total Energy Metabolism (in kcal)
according to Long et al. 1979
total metabolism = basal metabolism x activity factor x illness factor
activity factor
illness factor
bed rest
x 1,1
serious operation
little activity
x 1,3
fever
cancer
1,2 - 1,5
infections
for each increased °C + 13 %
example:
38 °C x 1,13
39 °C x 1,26
- little
- serious (sepsis)
- burn
 not in addition to illness factor
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/8/96
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x 1,2
x
x 1,3
x 1,6
x 1,5 - 2,0
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Increased Requirement of Energy
• diseases
• stress metabolism
• convalescence
• loss of energy-rich substances
• hormone disorders
• growth
• pregnancy (+ 300 kcal/d)
• lactation period (+ 700 kcal/d)
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/9/96
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Digestion
mouth
• food intake
 chewing and insalivation
 registration of taste
 initiation of digestion of starch
 transportation
stomach
• desinfection of chyme
 initiation of digestion of fat and protein
 dilution of chyme to decrease osmolarity
 deposition in portions into small intestine
(functioning as a reservoir)
esophagus
• transportation
 esophageal sphincter prevents reflux
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/10/96
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. Basic Care .
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Digestion
pancreas
gall bladder
• excretion of enzymes into small intestine
• storage of bile acids
- -amylase
( digestion of carbohydrates)  of bile acids into duodenum
- pancreas-lipase ( digestion of fat)
(emulsification of fats)
- peptidase
( digestion of protein)
• excretion of hormones into blood
- insulin
- glucagon
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/11/96
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Digestion
small intestine
large intestine
• reabsorption of water
- duodenum (0,3 m)
- jejunum (1,3 m)
- ileum (1,6 m)
- ileocecal valve
• resorption of electrolytes
• bacterial fermentation of
• enzymatic decomposition of nutrients
• resorption of nutrients and water
• reabsorption of bile acids
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/12/96
- not digested carbohydrates and
proteins
- dietary fibers
( short-chain fatty acids and gases)
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Location of Resorption for Different Nutrients
pancreatic
enzymes
bile
peptides,
fat amino acids water magnesium bile
salts
electrolytes,short-chain
fatty acids
water
colon
stomach
vitamines
calcium ferrum monosaccharid
es
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/13/96
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vitamin B12
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Areas of Resorption of Fats, Proteins and
Carbohydrates
stomach
duodenum
ileum
jejunum
fat
protein
carbohydrates
resorption in reserve
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/14/96
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Metabolism
Liver
• synthesis of fatty acids, ketone bodies, some proteins
(for instance albumin, transferrin, acute-phase proteins)
• regulation of amino acid pool in the blood
 production of bile acids
 storage organ for glycogen, vitamines
 detoxification of alcohol, drugs, ammonia
Blood
 transport of nutrients, oxygen and decomposition products
• transport of nutrients to organs
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/15/96
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Stoma Care
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Body Composition
1 kg
~ 1,5 % carbohydrates
9 kg
~ 13,8 % fat
11kg
~ 17,0 % protein
40 kg
~ 61,6 % water
4 kg
= 65 kg
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/16/96
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~ 6,1 % minerals
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Nutrients
Macronutrients
Micronutrients
• water
• vitamines
• protein
• minerals
• carbohydrates
• trace elements
• fat
• phytochemicals
• dietary fibers
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/17/96
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Carbohydrates
Monosaccharides = simple sugars
Polysaccharides
• glucose (grape sugar; glc)
 fructose (fruit sugar; fru)
 galactose (gal)
 xylose
• starch (glc-reserve in plants)
• dextrins (fragments of starch)
• glycogen (glc-reserve in animals)
• dietary fibers
Disaccharides = dual sugars
Glucose-substitutes
• saccharose (glc-fru) = unrefined sugar  sorbitol (alcohol of glucose)
 maltose
(glc-glc) = starch hydrolysate
 xylitol (alcohol of xylose)
 lactose
(glc-gal) = milk sugar
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/18/96
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Digestion of Carbohydrates
organ
enzyme
reaction
-amylase
mouth
dextrin

starch
 maltose
stomach
---
---
---
pancreas
-amylase
starch
 dextrin
 maltose
small intestine
fru
saccharose  glc +
saccharase
maltase
lactase
maltose
 glc + glc
lactose
glc + gal
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bacterial degradation of indigestible carbohydrates
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02

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Function of Carbohydrates

• energy substrate
• energy storage

1 g glucose = 4 kcal
in form of glycogen in liver and muscels
• component of membranes and intercellular substance
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Clinical Nutrition1/OPM Germany/Stand 02
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Significance of Glucose
•
the only energy source utilized by all body cells
•
obligatory fuel for:
1. central nervous system
(supply with energy after long periods of fasting also by ketone bodies)
2. erythrocytes
3. renal medulla
4. bone marrow
5. granulation tissue
•
daily minimum requirements: ca. 150 g
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/21/96
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Glycemic Index
example: glycemic index of oranges (53 %)
25 g glucose
= 25 g
carbohydrate
280 g oranges
= 25 g
carbohydrate
time (minutes)
time (minutes)
glycemic index = comparison of blood glucose above the fasting value
after administrating glucose and after test meal.
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Clinical Nutrition1/OPM Germany/Stand 02
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Glycemic Index
Substrate specific:
• quantity and quality of dietary fibers
• amount of indigestible starch
• processing of foods
• composition of meal
Subject specific:
• individual metabolism
• individual digestion
• medication (e. g. insulin)
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/23/96
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Digestion of Long-Chain Triglycerides (LCT)
organ
release of
stomach
acidic lipase
cholecystis
bile acid
pancreas
pancreas-lipases
reaction/function
TG  1 FFA (free fatty acid)
+ diacylglycerol
emulsification of fats
TG  2 FFA + monoacylglycerol
monoacylglycerol  1 FFA + glycerol
small intestine
- intestinal lumen --- intestinal cell
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/24/96
---
resorption of FFA, mono- and
diacylglycerol, glycerol
resynthesis to TG in chylomicrons,
release into lymphatic system
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Cellular Metabolism of Triglycerides
LCT
MCT
transport
lipoprotein-bound
as free triglycerides
hydrolysis in blood
and in liver
slowly
fast
transport liver
as triglycerides
as remnants of
chylomicrons and VLDL
transport into
mitochondrions
activation by
coenzyme A
carnitine-dependent transport
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/25/96
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Cellular Metabolism of Triglycerides
LCT
MCT
rate of oxidation
low
high
hepatic stress
high
low
stress of RES*
high
low
tissue-pexis
high
low
protein-saving effect
low
high
immune system
immuno-modulation
immunological neutral
* reticuloendothelial system
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/26/96
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Advantages of MCT-Fats compared to LCT-Fats
• fast resorption
• direct transport via portal vein into liver
• more efficient oxidation
• immunological neutral



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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/27/96

low liver burden
protein-saving effect
maintenance of immune-functions
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Functions of Fats
• energy substrate (triglycerides)
1 g fat = 9 kcal
• energy storage (triglycerides)
• cell structure
component of membrane (phospholipids)
• bioactive substances
(for instance for prostaglandins)
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/28/96
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Recommendations for Fat Uptake
relation of fatty acids
polyunsaturated
fatty acids
saturated/
monounsaturated/
polyunsaturated fatty acids
saturated
fatty acids
monounsaturated
fatty acids
• w-3 fatty acids: maximum of 3 % kcal
• relation of w-6 to w-3 fatty acids: 3 - 5 : 1
• polyunsaturated fatty acids: maximum of 10 % kcal
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/29/96
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Recommendations for Linoleic Acid Uptake
•
requirement of linoleic acid (w-6 FA) : 7 - 10 g/day (healthy
subjects)
in case of serious stress-metabolism requirement may double
•
excessive supply of linoleic acid
 imbalances of the pattern of fatty acids
 disorders of immune system
•
deficiency of linoleic acid (essential fatty acid deficiency/EFAD)
 disorders in wound healing
 skin alterations: xerosis, redness, incrustation
 thrombocytopenia
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/30/96
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Classes of Fatty Acids
w-9
example
oleic acid
C 18:1
w-6
example
linoleic acid
C 18:2
w-3
example
-linolenic acid
C 18:3
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/31/96
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=
=
COOH
=
COOH
=
=
=
COOH
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Protein Structure
 smallest unit: amino acid (AA)
 20 proteinogenous amino acids
 peptide bond between acid- and aminogroup
 peptides: chain of amino acids
- dipeptide:
2 AA
- oligopeptide: 3 - 10 AA
- polypeptide: > 10 AA
 globoid structure of amino acid chain by folding
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/32/96
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Proteinogenous Amino Acids
essential
non essential
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/33/96
valine
phenylalanine
threonine
leucine
tryptophan
lysin
isoleucine
methionine
glycine
aspartic acid
alanine
cysteine
tyrosine
proline
asparagine
arginine
serine
glutamine
histidine
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glutamic acid
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Digestion of Proteins
organ
enzyme
reaction
stomach
denaturation of proteins
pepsin
by acidic milieu
protein
trypsin
chymotrypsin
polypeptides  peptides
polypeptides  peptides

polypeptides
oligopeptides
pancreas
peptidases
large intestine
bacterial decomposition of not resorbed protein
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/34/96
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peptides
 amino
small intestine
acids
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Functions of Amino Acids and Proteins
• component for synthesis (amino acids)
 muscels
 structure proteins
(organs, connective tissue)
 hormones
 transport protein
 immunoglobulins (antibodies)
 enzymes
 membrane proteins
• energy substrate in case of malnutrition
1 g protein = 4 kcal
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Nitrogen Balance
NBal
=
Nin - Nout
Nin
=
N-intake (proteins or amino acids)
Nout
=
N-excretion through urine
+ correction for feces + skin
anabolism
positive N-balance = Nin > Nout
catabolism
negative N-balance = Nin < Nout
(N= chemical symbol for nitrogen)
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/36/96
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Metabolic Pathways in Anabolism and
Catabolism
anabolism
catabolism
glucose
glycogenesis
liponeogenesis
glycogenolysis
fat
protein
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Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/37/96
glycolysis
lipogenesis
lipolysis
protein synthesis
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proteolysis
gluconeogenesis
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Physiological Significance of Glutamine
• most frequent free intra- and extracellular amino acid
 non essential proteinogenous amino acid
 nitrogen- and carbon-transport molecule
 substrate for gluconeogenesis
 energy substrate of enteroytes, fibroblasts, lymphocytes
 substrate for synthesis of RNA- and DNA-precursors
 antioxidative effect (glutathione peroxidase)
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Glutamine in Critical Illness
Trauma
• release of glutamine from muscels (and lungs),
partly from liver and intestinum.
• energy substrate for cells of immune system and fibroblasts
around wound area.
Sepsis
• release of glutamine from muscels (and lungs),
partly from intestinum and kidney.
• energy substrate for immune system,
liver and intestinum.
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Water Balance
out
in
food 1 L
beverages 1,2 L
respiratory air
950 mL
perspiration
oxidation water 300 mL
urine 1,4 L
feces 150 mL
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Function of Water
• solvent (dilution)
• transport medium
• temperature regulation (perspiration)
 survival without fluid intake: maximum of 3-4days
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Dietary Fibre
Carbohydrates, which cannot be broken down by
the enzymes in the human intestinal tract
(indigestible) as well as lignin
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Classification of Dietary fibre
Indigestible polysaccharides
depending on the analyses methods used classified as
- NSP = non-starch polysaccharides
- TDF = total dietary fibre
This definition does not include other indigestible constituents of food,
which act similar to dietary fibre in the intestine, e.g.:
- Polyalcohols
- Polydextroses
- indigestible proteins
- indigestible lipids, waxes and fat
replacement substances
- Fructo-oligo-saccharides - Maillard products
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/43/96
B|BRAUN
OPM
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. Basic Care .
Wound Care .
Diabetic Care
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Incontinence Care
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Infusion Care
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Nutrition Care
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Indigestible Constituents of Food
• are only indigestible for human digestive enzymes
• reach the colon virtually unchanged
• can be fermented by bacterial enzymes
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/44/96
B|BRAUN
OPM
Stoma Care
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. Basic Care .
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Dietary Fibre
Insoluble
Soluble
Lignin
Gums (gummi arabicum, guar)
Cellulose
ß-Glucanes (oats, barley)
Hemi-cellulose
Pectin
Resistant starches
Mucous substances
Inulin
Fructo-oligo-saccharides (FOS)
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/45/96
B|BRAUN
OPM
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Dietary Fibre
Carbohydrates
Indigestible
carbohydrates
(dietary fibre)
Monosaccharides
+
Disaccharides
Non- starch
polysaccharides
(dietary fibre)
Starch- polysaccharides
(Resistant starches)
Soluble
insoluble
GP: Degree of polymerisation
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/46/96
Indigestible
oligo- saccharides
Dietary fibre with prebiotic effect= prebiotics
B|BRAUN
OPM
Polysaccharide
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Fermentation of Dietary Fibres by Bacteria in the Colon
Dietary Fibre

Lignin
Cellulose
Hemi-cellulose
Decomposition Products
• Short-chain fatty acids
- Butyric acid (butyrate)
- Propionic acid (propionate)
- Acetic acid (acetate)
Pectin
Gums
Mucous substances
Inulin
Oligo-fructose
Resistant starches
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/47/96
• Gases
- Carbon dioxide (CO2)
- Hydrogen (H2)
- Methane (CH4)
B|BRAUN
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. Basic Care .
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Effects of Dietary Fibres
•  Fermentation products: short-chain fatty acids
•  Faecal volume
-
- Water binding
- Biomass/bacteria
 Reduction of diarrheas and obstipation
•  Gastro-intestinal transit time
•  Carcinogenesis by diluting carcinogens
and toxins in the faeces
•
Blood sugar levels
•
Cholesterol
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/48/96
B|BRAUN
OPM
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Stoma Care
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Long-Term Effects of Dietary Fibres
•  Gall stones
•  Inflammatory intestinal illnesses
•  Ulcus duodeni
•  Haemorrhoids
•  Irritable intestine
•  Colon carcinomas
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/49/96
B|BRAUN
OPM
Nutrition Care
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Stoma Care
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Stoma Care
Prebiotics
Indigestible constituents of food, which have an effect
on the organism (man), which
• selectively and specifically promote the growth
and/or the activity of one or a limited number of
bacteria in
the intestine
• have the potential to improve health
(Gibson & Roberfroid, 1995)
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/50/96
B|BRAUN
OPM
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Probiotics
Preparation or product from vital, defined microorganisms
• in an adequate number
• change the microflora in a section of the host‘s body as
a
result of implantation or colonisation
• exert a favourable effect on the health of the host
(Havenaar & Huis In‘t Veld, 1992; Schrezenmeir & de Vrese, 2001)
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/51/96
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Symbiotics
Mixture of pre- and probiotica, which favourably affect
the host
• by implantation of living microorganisms in the
gastrointestinal tract
• by improving the survival of the probiotica
(Gibson & Roberfroid, 1995)
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/52/96
B|BRAUN
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Intestine: Functional Differences
Small intestine
Colon
• Digestive secretions from: • no human digestive secretions
stomach, pancreas, bile &
• pH 6 - 7
intestines
• high degree of bacteria
• pH approx. 2 – 6.5
colonisation
• low bacteria colonisation
• surface enlargement due to
• surface enlargement:
Lieberkühn‘s crypts, brush
Kerckring‘s folds, villi,
border
(Lieberkühn‘s crypts),
brush border
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/53/96
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Surface Protection
Probiotic bacteria (e.g. lacto-bacillae)
Phospholipids
Surface protection
system
Mucous
membrane
Intestinal
epithelium
cells
Beaker
cells
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/54/96
Phospholipids
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Intestinal Flora
Totality of all bacteria in the intestines (type and number)
• approx. 10 14 (100,000,000,000,000) cells
• approx. 400 - 500 different species
• influenced by
- regions (Europe, Japan, North America, etc.)
- age
- nutrition (breast-feeding/ready-made meals,
regions)
- diseases
- medication (antibiotics, chemo-therapy drugs)
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/55/96
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Bacterial Fermentation
Breakdown of nutrients by bacterial enzymes
• partial aerobic fermentation in the small intestine
• Anaerobic biosis in the colon (lack of oxygen)
-> fermentatie only to intermediate products
(short-chain fatty acids, lactate, gases, etc.)
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/56/96
B|BRAUN
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Bacterial Colonisation of the Intestine
Stomach (1) and duodenum
(2)
Colon (5)
(1010 - 1012 KBE/mL)
(101 - 103 KBE/mL)
1
Lactobacillae
Streptococci
Yeasts
Jejunum (3) and Ileum (4)
2
3
(104 - 108 KBE/mL)
Lactobacillae
Coliforms
Streptococci
Bacteroids
Bifidobacterium
Fusobacterium
4
5
(KBE=Colony forming units oer ml intestinal content org
faeces)
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/57/96
B|BRAUN
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Bacteroids
Bifido bacterium
Streptococci
Eubacterium
Fusobacterium
Coliforms
Clostrides
Lactobacillae
Proteus
Staphylococci
Pseudomonades
Yeasts
Protozoa
. Basic Care .
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Fermentation Substrates
Approx. quantity consumed by substrate
(g/day)
Carbohydrates
Resistant starch
Non-starch polysaccharides
– 18
Unabsorbed sugar and sugar alcohols
– 10
Oligo-saccharides
Chitin and amino sugar
Synthetic carbohydrates:
Lactulose, lactitol, polydextrose, etc
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/58/96
B|BRAUN
OPM
8 – 40
8
2
2- 8
1- 2
.
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Fermentation
Indigestible
carbohydrates
- Polysaccharide
- Oligosaccharide
- Monosaccharide
Secretion products
Cell constituents
Bacterial hydrolysis
of the complex carbohydrates
Lactate
Ethanol
Succinate
Bacterial
biomass
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/59/96
Bacterial
fermentation
Short- chain fatty acids
- Acetate
- Propionate
- Butyrate
B|BRAUN
OPM
Gases
Carbon dioxide
Hydrogen
Methane
H2S
.
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Effects Short Chain Fatty Acids
• Energy substrate for colonocytes
• Promotion of mucosal blood circulation
• Anti-diarrhea effect due to coupled absorption with sodium and
water
•  Mucous secretion of the mucosa =  surface protection layer
• Cell proliferation of the intestinal epithelium
• Cell differentiation:  mutagenic cells due to butyrate
• Post-operative outcome, colitis
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/60/96
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The Probiotic Concept
Administration of a preparation or a product with probiotic
bacteria
• Living cultures
• Must remain vital under use and storage
• Must survive the passage through stomach and small
intensive
(gastric acids, bile, etc.)
• Shall change microflora in a section of the intestines,
through implantation or colonisation
• Induce health benefits for the host
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/61/96
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Probiotic Bacteria
Bifido bacteria
• Approx. 25 % of the bacteria population in an adult human,
up to 95 % in newborn babies
• Produce vitamins (mostly B-vitamins)
• Saccharolytic bacteria
• Metabolic end products:
strong acids, mostly acetate and lactate
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/62/96
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Probiotic Bacteria
Bifido-bacteria:
potential health-promoting effects
•  pH-value, blocks pathogenic microorganims, promotes
acidophilic bacteria
• Secretion of bacteriocines = block pathogenic
microorganisms
• Beneficial for intestinal flora during antibiotics therapy
• Act as immune modulators against malign cells &
pathogenic microorganisms
• Acidification promotes detoxification of potential
toxic
substances (e.g. ammonia)
Basics
of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/63/96
B|BRAUN
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Probiotic Bacteria
Lacto-bacillae
• Metabolic end products: short-chain fatty acids
•  pH-value, blocks pathogenic microorganisms, promotes
acidophilic bacteria
• Secretion of bacteriocines = inhibit pathogenic
microorganisms
• Removal of potential toxic substances
• Stimulation of the immune system
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/64/96
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“Colonic Food“ - Prebiotics
Carbohydrate
Prebiotic
Colonic food
Resistant starches
Non-starch polysaccharides
cell wall polysaccharides
Hemi-cellulose
Yes
(Yes)
Yes
No
Pectin
Yes
Gums
Yes
Indigestible oligo-saccharides
Fructo-oligo-saccharides
Yes
Galacto-oligo-saccharides
Yes
Basics of Nutrition
Soy – oligo-saccharides B|BRAUN
Yes
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/65/96
OPM
Yes
No
No
No
Yes
?
?
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Resistant Starches
• Starches, which reach the colon undigested
• 10 % of the starch eaten is resistant starch
• uptake per day: 8 - 40 g
• Different types of resistant starches (RS)
- RS1: physically resistant starches
- RS2: granular starch
- RS3: retrograded starch
• Digestibility depends on
- the structure of the starch (amylose, amylopectin)
- the preparation (raw, cooked, cooled, water content)
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/66/96
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Resistant Starches
• bacterial fermentation to short-chain fatty acids,
especially butyrate
•  energy supply for the colon
• in animal trials
- bifidogenic
- promotion of lactobacillae
• reduces increase in blood sugar levels
• probably anti-carcinogenic
- detoxification of carcinogens e.g. sec. bile acids
• promoted mineral absorption by RS2
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/67/96
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Prebiotics
Prebiotics (fructo-oligo-saccharides)
- Oligo-fructose
(GP 2- 20)
- Inulin
(GP 2- 60)
Potential prebiotics
- resistant starch
- Galacto-oligo saccharides
- Soy oligo-saccharides
- Raffinose
- Lacto-sucrose
- Lactulose
(GP 3-6)
(GP 3)
(GP 3)
(GP 3)
(GP 2)
GP = Degree of polymerisation
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/68/96
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Occurrence of Prebiotics
Oligo-fructose and inulin
Bananas
Chicory
Garlic
Leeks
Rye
Asparagus
Topinambour
Wheat
Onions
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/69/96
Resistant starches
Maize
Rice
Barley
Wheat
Leguminous plants
Potatoes
Bananas
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OPM
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Structure of Prebiotics
Saccharose structure of oligo-fructose and inulin
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/70/96
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Definition of Prebiotics
• Verification of indigestibility in the small intestine
- treatment with human digestion secretions
- patients with terminal ileal stoma
• Verification of the prebiotic effect
- in-vitro investigations
- in-vivo studies human
 Oligo-fructose & inulin are bifidogens
• Luminal effects
-  bacteroides, clostridia, enterobacteria
-  faecal quantity by approx. 1.5 - 2 g/g OF or inulin
-  short-chain fatty acids:  energy substrate
colonocytes
-  pH
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/71/96
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Effects of the Prebiotics
• systemic effects
-  short-chain fatty acids: acetate, propionate
• luminal effects
-  mineral absorption (Ca, Mg, Fe)
-  carcinogenics (elimination, detoxification, inhibition
of
carcinogenic bacterial enzymes)
-  carcinogenesis due to the effect on cell proliferation
and cell differentiation
• potential systemic effects
- improvement of the glucose and lipid parameters
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/72/96
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Advantages of Pre- vs Probiotics
• No living cultures
- manufacture
- storage
- application
• specific nutrition for probiotic bacteria
= selective promotion of the bacteria that have already
settled
• Conditions for the implantation or colonisation with
probiotica
- Settlement only successful under selective
conditions
- Competition with the existing flora
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/73/96
B|BRAUN
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Nutricomp Dietary Fibre Concept
Inulin
20 %
Soya dietary fibre
30 %
Gum arabicum
Resistant starch
20 %
15 %
Cellulose
8%
Pectin
7%
insoluble
soluble
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/74/96
41 %
59 %
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Basic Principles for Nutrient Intake
about
2 liters beverages
about 30g dietary fibers
energy substrate distribution
protein
15%
fat
30%
55%
carbohydrates
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/75/96
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Nutrient Requirement for Children
• high energy requirement per kg body weight
dependent on age: 100 - 50 kcal/kg body weight
 high fluid requirement
dependent on age: 140 - 40 ml/kg body weight
• recommended relation of nutrients (% kcal)
protein :
fat
:
carbohydrates
8 - 12 :
30 - 40 : 50 - 60
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/76/96
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Nutrition Care
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Nutrient Requirement of Elderly People
steady or increasing requirement of
critical nutrients and reduced energy
requirement

high nutrient density and low energy
intake
critical macronutrients
• protein
• water
• dietary fibers
critical micronutrients
• vitamines: A, D, E, C, B1, B2,
B6, folic acid
• minerals: K, Ca, Mg
• trace elements: Fe, Zn
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/77/96
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Protein / Amino Acids Requirement in Clinical
Nutrition
state of metabolism
g / kg body weight and day
good nutritional status
0,8 - 1,0
renal insufficiency
0,6 - 0,8
dialysis
1,2
hepatic insufficiency
mild catabolism
1,0 - 1,2
catabolism
1,2 - 1,5
serious catabolism
(sepsis, burn,etc.)
1,5 - 2,5
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/78/96
0,5 - 1,2
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Fluid Requirement in Clinical Nutrition
30 - 40 ml/kg body weight and day
body weight
1. - 10. kg
11. - 20. kg
21. - 50. kg
each further kg
requirement
example in case of 70 kg body weight
100 mL/kg
50 mL/kg
20 mL/kg
10 mL/kg
1000 mL for 10 kg
500 mL for further 10 kg
600 mL for further 30 kg
200 mL for further 20 kg
total
2300 mL/day
additional requirement of fluid in cases of: • fever • diarrhea,
vomiting
• sweating
• polyuria
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/79/96
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Determination of Requirements (rough calculation)
Energy
activity of the patient
 bedfast
 sedentary
 mobile
25 kcal/kg body weight
30 kcal/kg body weight
35 kcal/kg body weight
total energy requirement
(___ kcal x ___ kg body weight) = ___ kcal/d
Fluid
requirement of the patient
 normal
 increased (for instance: sweating)
 high (for instance: sweating + fever)
total requirement
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/80/96
30 mL/kg body weight
35 mL/kg body weight
40 mL/kg body weight
(___ ml x ___ kg body weight) =
B|BRAUN
OPM
___ mL/d
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Micronutrients
• vitamines
• minerals
• trace elements

essential nutrients, which have to be supplied daily
in a sufficient dose
• phytochemicals

non essential nutrients with a prophylactic effect
for infections, cancer, cardiovascular diseases
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/81/96
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Vitamines
fat-soluble vitamines
water-soluble vitamines
vit. A
vit. D
vit. E
vit. K
vit. C
ascorbic acid
vit. B1
thiamine
vit. B2
riboflavin
vit. B6
pyridoxine
vit. B12 cobalamin
folic acid
biotin
pantothenic acid
niacin
retinol
calciferol
tocopherol
antihemorrhagic factor
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/82/96
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Biological Significance of B-Vitamines
Metabolic cofactors
• carbohydrates
• fat
• protein/amino acids
Possible deficiency symptoms
• skin alterations (vit. B2, vit. B6, biotin, pantothenic acid)
• neuritis, lactate-acidosis (vit. B1)
• cramps (vit. B6)
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/83/96
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Stoma Care
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Stoma Care
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Biological Significance of Fat-Soluble Vitamines and Vitam
• protective factors
 antioxidants: vitamines C, E, ß-carotin
• mineral metabolism (calcium)
 vitamin D
• visual function, epithelial protection
 vitamin A
• blood coagulation
 vitamin K
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/84/96
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Minerals
• sodium
• potassium
• calcium
• magnesium
• phosphate
• chloride
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2003-01-09/85/96
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Stoma Care
Biological Significance of Minerals
osmotic function
 water and acid-base balance (phosphate, sodium, potassium,
chloride)
 regulation of osmotic pressure (sodium, potassium, chloride)
structural function
 construction of bone and dental construction (calcium, phosphate)
metabolic function
 energetic metabolism (phosphate)
 enzyme activation (calcium, magnesium, sulfate)
 development of hydrochloric acid in stomach (chloride)
signal trransduction
 nerves, muscels, heart
(calcium, magnesium, potassium, sodium, chloride)
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2003-01-09/86/96
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Trace Elements
• iron
• manganese
• zinc
• molybdenum
• copper
• selenium
• iodine
• cobalt
• chromium
• fluorine
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2003-01-09/87/96
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Biological Significance of Trace Elements
catalytic function as a complement of enzymes and other proteins
 wound healing (zinc)
 immune functions (zinc)
 hormone functions (iodine)
 antioxidative function (selenium)
 oxygen transport (iron)
 respiration (chromium)
dental mineralisation (fluorine)
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2003-01-09/88/96
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Phytochemicals
polyphenols
in cereals, green cabbage, artichokes, berries
sulfides
in onions, garlic, asparagus
carotenoids / terpenes
phytosterols
in many vegetables and fruits
cholesterol-like substances from nuts
and vegetable seeds
glucosinolates
in cruciferous plants (cabbages, radish,
flavonoids
more than 5000 substances,
common in most foods
phytoestrogens
in cereals, legumes, especially in soya
saponins
lectins
protease-inhibitors
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/89/96
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Biological Significance of Phytochemicals
Possible effects
carotenoids
phytosterols
saponins
glucosinolates
polyphenols
protease-inhibitors
monoterpenes
phytoestrogens
sulfides
lectins
A = anticarcinogen
B = antimicrobial
C = antioxidative
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A
x
x
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B
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C
x
D
E
F
G
I
J
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H
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D = antithrombotic
G = influence on blood pressure
E = immunomodulating H = anti-cholesteremic
F = anti-inflammatory
I = influence on blood glucose
J = digestive
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Nutrients with Antioxidative Effect
not-enzymatic antioxidants
enzymatic antioxidants
• water-soluble
- glutathione peroxidase (Se, Gln)
- superoxide dismutase (Cu, Zn)
- protease-inhibitors
- ascorbic acid (vitamin C)
- cysteine
- flavonoids, polyphenols, sulfides
• fat-soluble
- tocopherol (vitamin E)
- carotenoids / terpenes
- phytoestrogens
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2003-01-09/91/96
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Antioxidants
Functions of antioxidants
• cofactors of wound healing
• stimulators of humoral and cellular immune reaction
• prevention of sickness (cancer, cardiovascular diseases)
• scavengers of free radicals
Characteristics of free radicals
• high reactivity because of unpaired electrons
 low intra- and extracellular concentration
 short biological half-life period
• initiating chain reactions
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2003-01-09/92/96
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Influence of free Radicals on Cell Metabolism
lipid peroxidation
 lesion of cell membranes
denaturation of proteins
 loss or alteration of enzymatic functions
damage of nucleic acids / DNA
 mutagens or cytotoxic effects
 stimulation of virus replication
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2003-01-09/93/96
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Role of Antioxidants in case of Cancer and AIDS
- decreased oral nutrient intake
- maldigestion/malabsorption
decreased
- increased losses because of diarrhea and vomiting antioxidants
- lower bioavailability of nutrients because of
interactions between nutrients and drugs
- radiation- and chemotherapy
increased
free radicals
- radiation- and chemotherapy
- immune reactions
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2003-01-09/94/96
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Monitoring
Anthropometry
Bioelectric impedance analysis
• body weight (kg)
differentiation of body compartments:
• height (m)
• body fat
• body-mass-index (BMI=kg/ m2)
• body cell mass
• extracellular mass
• circumference of hip, waist, upper arm
• skinfold thickness
(measure of subcutaneous fat )
• body fluid
• muscular strength
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/95/96
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Monitoring
general data:
laboratory data:
• basic disease
 glucose
• gastrointestinal function
 albumin (long biological half-live periods)
• feces
 cholinesterase, retinol-binding protein,
transferrin (short biological half-live periods)
• temperature
• fluid status
 triglycerides
 urea/creatinine
 electrolytes
 hepatic enzymes
Basics of Nutrition
Clinical Nutrition1/OPM Germany/Stand 02
2003-01-09/96/96
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