NUTRITION

FULL

FUNDAMENTAL OF NUTRITION

1. Flashcard 1 — Define nutrition and distinguish macronutrients from micronutrients.

2. Differentiate whole grains, refined grains, enriched grains, legumes, pulses and dietary fibre.

3. — Differentiate essential and nonessential amino acids and fatty acids.

4. What are the major functions of carbohydrates, and what happens when glucose is insufficient?

5. What carbohydrate, fibre and sugar recommendations are given in the lecture?

6. What is the glycemic index, and how do low- and high-GI foods differ?

7. What are the functions of proteins, and how are protein quality and biological value determined?

8. — What are complementary proteins, and what are the adult protein recommendations?

9. — What are the major functions of fats, and how are energy-yielding nutrients compared?

10. What key micronutrient recommendations and basic food-group principles should you remember?

A patient presents with megaloblastic anemia and subacute combined degeneration of the spinal cord. Dietary history reveals strict veganism with zero intake of animal products or fermented foods. Which micronutrient deficiency is responsible?- cynacobalamine

A 60-year-old chronic alcoholic patient presents with acute mental confusion, ophthalmoplegia, and ataxia. Which vitamin deficiency underlies this neurological emergency?

• A.

  Thiamine

  (Your answer)

  Correct answer

  Thiamine (Vitamin B1) deficiency precipitates Wernicke-Korsakoff syndrome in chronic alcoholics due to impaired intestinal absorption and increased metabolic demand.

• 
  

A patient presents with classic clinical signs of Pellagra, characterized by dermatitis, diarrhea, dementia, and potentially death. Which vitamin deficiency is responsible for this condition?niacin

Which classification of lipids is characterized by having hydrocarbon chains connected by double bonds oriented in opposite planes, creating a linear form that resembles a saturated fat?trans fat

dietry fats emulsifies fts in small intestines

vitamin c - collagen hydroxylation

Which mineral functions as a critical intracellular cation maintaining fluid balance and resting membrane potentials across excitable neural and muscle tissues?- pottasium

Which oil is highlighted in the "Pro Tips for Fat" section as being 92% saturated fat? coconut oil

1. Answer:

   • Nutrition: Study of food, nutrients, their actions/interactions, and relationship to health and disease; includes ingestion, digestion, absorption, transport, utilization and excretion.

   • Macronutrients: Carbohydrates, proteins and fats; needed in larger amounts and provide energy.

   • Micronutrients: Vitamins and minerals; needed in smaller amounts.

   • Water is inorganic; vitamins are organic; proteins contain nitrogen.

2. Answer:

   • Whole grains: Contain bran, germ and endosperm.

   • Bran: Fibre, vitamins and minerals.

   • Germ: Vitamins, healthy fats and other plant nutrients.

   • Endosperm: Mainly starch, some protein and few vitamins/fibre.

   • Refined grains: Bran and germ removed.

   • Enriched grains: Some nutrients removed during refining are added back.

   • Legume: Plant from the Fabaceae family.

   • Pulse: Edible seed of a legume, e.g. lentils, beans and peas.

   • Dietary fibre: Plant material not completely digested by human enzymes.

3. Answer:

   • Essential amino acids: Cannot be synthesized adequately by the body; must come from the diet.

   • Nonessential amino acids: Can be synthesized by the body.

   • Essential fatty acids: Must be obtained from food; include omega-3 and omega-6 polyunsaturated fatty acids.

   • Nonessential fatty acids: Can be synthesized by the body.

   • Saturated fats have no double bonds; unsaturated fats have at least one.

   • Trans fats increase blood cholesterol and cardiovascular disease risk.

4. Answer:

   • Primary energy source, especially during moderate/severe muscular activity.

   • The CNS normally depends on glucose; adaptation to ketone utilization takes approximately 5–7 days according to the lecture.

   • When glucose is insufficient, the body can synthesize it from amino acids/protein, but not from fatty acids directly.

   • Adequate carbohydrate has a protein-sparing effect.

   • Fibre helps prevent constipation and may reduce the risk of diverticular disease and other chronic diseases.

5. Answer:

   • Carbohydrate RDA: 130 g/day for adults and children, as stated in the lecture.

   • Fibre adequate intake: 14 g per 1,000 kcal.

   • At least 50% of grain servings should be whole grains.

   • Fruits and vegetables: at least 5 servings/day.

   • Increase fibre gradually and drink adequate fluids.

   • Limit added sugars; the lecture states a maximum of 25% or less of total calories from added sugars.

   • Whole grains and adequate fibre are associated with better bowel health, weight management and reduced cardiometabolic risk.

6. Answer:

   • Glycemic index (GI): Ranks foods by how quickly they raise blood glucose.

   • Low GI: Slower, steadier glucose release; may help with weight management and is preferred in diabetes according to the lecture.

   • High GI: Faster glucose release; useful for rapid energy recovery after exercise or correcting insufficient glucose.

   • Glycemic load: Considers how much glucose a food delivers, not only how quickly glucose enters the bloodstream.

   Exam trap: GI and glycemic load are related but not identical.

7. Answer:

   • Proteins support growth, tissue maintenance/repair, enzyme synthesis and immune defence.

   • Proteins are polypeptides broken down into amino acids during digestion.

   • High biological value (BV): Essential amino acid composition matches human requirements.

   • Complete proteins: Provide adequate amounts of all essential amino acids.

   • Animal proteins and soy are examples of complete/high-quality proteins in the lecture.

   • Incomplete proteins: Lack adequate amounts of one or more essential amino acids; gelatin is also incomplete.

8. Answer:

   • Complementary proteins: Two protein sources combined to provide adequate proportions of all essential amino acids.

   • Examples: beans + rice, peanut butter + bread, lentils + rice, cereal + milk.

   • They do not need to be eaten at the exact same meal.

   • Adult protein RDA: 0.8 g/kg/day.

   • Acceptable macronutrient distribution range: 10–35% of total calories.

   • RDA is intended for healthy people.

9. Answer:

   • Fats are major energy stores and important energy sources during starvation/emergencies.

   • Help absorb fat-soluble vitamins A, D, E and K.

   • Support organs such as the heart, kidneys and intestines.

   • Cholesterol-related steroids act as regulatory compounds.

   Energy per gram:

   • Carbohydrates: 4 kcal/g

   • Protein: 4 kcal/g

   • Fat: 9 kcal/g

   Adult energy distribution in the lecture:

   • Carbohydrates: 45–65%

   • Fat: 20–35%

   • Protein: 10–35%

10. Answer:

    • Sodium: Lecture states 100 mEq/day, equivalent to approximately 2.3 g sodium or 6 g sodium chloride.

    • Calcium: At least 1,200 mg/day for postmenopausal women.

    • Vitamin D: At least 400 IU/day in younger individuals and 800 IU/day in older adults, as stated in the lecture.

    • Vitamins A, C and E are listed as antioxidants.

    • Main food groups: grains; fruits and vegetables; dairy; protein-rich foods.

    • An adequate diet supplies all required nutrients in appropriate total amounts.

    • Junk foods: Often high in calories from sugars/fats and low in protein, vitamins or minerals.

    • Empty-calorie foods: Provide energy but little protein, vitamins or minerals.

    Note: These numerical recommendations are reproduced from your lecture for exam revision; some may differ from current age-specific dietary guidance.

    Rapid-recall checklist

    Before moving to practice questions, make sure you can recall these without looking:

    Recall progress

    0/10

    Whole vs refined vs enriched grains; bran, germ and endosperm

    Essential vs nonessential amino acids and fatty acids

    Saturated vs unsaturated vs trans fats

    Carbohydrate functions and protein-sparing effect

    Carbohydrate RDA, fibre intake and whole-grain recommendations

    Glycemic index vs glycemic load

    Protein functions, BV and complete vs incomplete proteins

    Complementary protein examples and adult protein RDA

    Fat functions, energy per gram and macronutrient percentages

    Sodium, calcium, vitamin D and food-group recommendations

    Reset checklistFUN

FUNDAMENTAL OF NUT 2

1. What defines a healthy diet, and what are its main benefits?

2. What are Dietary Reference Intakes (DRIs), and how do EAR, RDA, AI and UL differ?

3. Define EER and AMDR. What adult macronutrient ranges are given in the lecture?

4. How do you calculate calories from AMDR percentages?

5. — Differentiate moderation, nutrient density and energy density.

6. What does the traditional food pyramid recommend?

7. What is the food exchange system, and how is it useful?

8. What are the key principles of the Mediterranean, Emirati and planetary health diets?

9. — How should healthy weight and weight-loss progress be assessed?

10. What weight-loss calculations and practical dietary habits should you know?

Bottom of pyramid are breads (starches), eat 6-11 servings/ day. Next level is fruits (2-4 servings) and vegetables (3-5 servings). Next level are dairy (2-3 servings) and meat ( 2-3, 3 oz servings). Finally, top of pyramid are fats and sugars, to be used sparingl

30gms provide 20g of carbs and 2 grams of protiens

50 grams of calorie 5.5g fat

The Mediterranean Diet ◼ Eat lots of vegetables ◼ Change the way you think about meat. ◼ Enjoy some dairy products ◼ Eat seafood twice a week ◼ Cook a vegetarian meal once a week. ◼ Use good fats: olive oil, seeds, peanuts ◼ Switch to whole grains ◼ For dessert ,eat fresh frui

(Food Exchange Systems were created by the American Diabetic Association, American Dietetic Association, and US Public Health Services).

To lose 1 kg per week, you need a daily deficit of 1,000 calories)

According to the Harvard Healthy Eating Plate, potatoes and French fries don't count toward your vegetables

Fruits, vegetables, whole grains, olive oil, beans, nuts, and seeds form the base of the Mediterranean Diet pyramid

LESS MEAT AND SUGAR

RDA CANT ASSESS A GRUP

1. Answer:
   A healthy diet:

   • Meets energy needs and provides sufficient macro- and micronutrients.

   • Supports growth, pregnancy and lactation.

   • Helps maintain glycaemic control, optimal blood lipids and healthy body weight.

   • Reduces chronic disease risk.

   • Is safe, with low levels of contaminants and potentially harmful added substances.

   Benefits include healthy growth and school performance in children, productivity and well-being in adults, and reduced risk factors for obesity, hypertension and hypercholesterolaemia

2. Answer:

   • DRIs: Reference values used to plan and evaluate diets of healthy people.

   • EAR (Estimated Average Requirement): Meets the needs of approximately 50% of healthy people in a specific age/sex group; used to calculate the RDA.

   • RDA (Recommended Dietary Allowance): Meets the needs of approximately 97–98% of healthy people in a specific age/sex group.

   • AI (Adequate Intake): Estimated recommended intake used when evidence is insufficient to establish an RDA.

   • UL (Tolerable Upper Intake Level): Highest daily intake unlikely to cause harm; exceeding it increases toxicity risk.

   Exam trap: The RDA is not the same as the EAR, and the UL is not a target intake.

3. Answer:

   • EER (Estimated Energy Requirement): Daily energy needed based on age, weight, sex, height and activity level.

   • AMDR (Acceptable Macronutrient Distribution Range): Percentage of total energy from each macronutrient associated with reduced chronic disease risk while meeting nutrient needs.

   For adults aged 19 years or older, the lecture gives:

   • Carbohydrates: 45–65%

   • Fat: 20–35% (with a stated goal of ≤30%)

   • Protein: 15–35%

   • Refined and processed sugars: ≤25% of total calories, with a stated goal of 10%.

4. Answer:
   Multiply total daily calories by the relevant percentage.

   Example: for a 2,150-kcal diet:

   • Carbohydrates: \(2150 \times 0.45 = 968\) to \(2150 \times 0.65 = 1398\) kcal/day.

   • Fat: \(2150 \times 0.20 = 430\) to \(2150 \times 0.35 = 753\) kcal/day.

   Energy per gram:

   • Carbohydrates = 4 kcal/g

   • Protein = 4 kcal/g

   • Fat = 9 kcal/g

   Exam trap: Convert the percentage to a decimal before multiplying.

5. Answer:

   • Moderation: Control portions and limit excess added sugar, salt, saturated/trans fats, cholesterol and alcohol.

   • Nutrient density: Nutrients provided relative to calories; choose foods with more nutrients for fewer calories. Example: skim milk instead of soda.

   • Energy density: Calories per gram of food. Fat has the highest energy density of the three energy-yielding nutrients.

6. Answer:
   According to the pyramid shown in the lecture:

   • Grains/starches: 6–11 servings/day at the base.

   • Fruits: 2–4 servings/day.

   • Vegetables: 3–5 servings/day.

   • Dairy: 2–3 servings/day.

   • Meat: 2–3 servings of 3 oz each.

   • Fats and sugars: use sparingly.

   General healthy-diet principles also include choosing whole grains, eating a variety of fruits and vegetables, moderating sugar, limiting salt and saturated fat, and keeping food safe.

7. Answer:
   A meal-planning system originally developed to help people with diabetes substitute foods with similar nutrient and calorie contents.

   • Six exchange lists: fruits, vegetables, milk, starches, fats, and meats/meat substitutes.

   • Foods within a list have broadly similar carbohydrate, protein, fat and calorie contents.

   • One item can be substituted for another on the same list in the specified portion.

   • Benefits: variety, calorie control, moderation, balanced meal planning and management of carbohydrate intake.

   • Limitations: may initially be complicated, and one exchange does not necessarily equal one ordinary serving.

8. Answer:

   • Mediterranean diet: Plenty of vegetables, fruits, whole grains, legumes, nuts, seeds and olive oil; seafood at least twice weekly; moderate dairy, poultry and eggs; meat and sweets less often; physical activity and shared meals.

   • Emirati food guidelines: Healthy eating and physical activity throughout life; reduce excess calories, sugar, saturated/trans fats and salt; choose diverse, nutrient-rich foods; replace unhealthy foods with healthier alternatives; ensure food safety.

   • Planetary health diet: More plant-based foods—whole grains, fruits, vegetables, nuts and legumes—with smaller proportions of animal-source foods, particularly red meat, to reduce environmental impacts.

9. Answer:

   • Weight change depends on the balance between calories consumed and calories expended.

   • BMI: Relates body weight to height.

   • Waist-to-hip ratio: Calculated as waist circumference ÷ hip circumference, as stated in the lecture.

   • Body-fat percentage: Proportion of total body weight that is fat.

   • Set short- and long-term goals, make sustainable lifestyle changes, and keep a food/activity journal.

   The lecture describes 1–2 lb/week as a safe and effective weight-loss rate

10. Answer:
    Lecture calculations:

    • 1 lb of fat ≈ 3,500 kcal.

    • A 500-kcal daily deficit × 7 days = 3,500 kcal/week, corresponding to approximately 1 lb/week.

    • A 1,000-kcal daily deficit × 7 days = 7,000 kcal/week, corresponding to approximately 2 lb/week.

    • The lecture also gives a theoretical 1-kg/week target as a 7,000-kcal weekly deficit, or 1,000 kcal/day.

    Practical habits:

    • Eat breakfast and choose nutrient-rich snacks, such as fruit, yoghurt, vegetables and chickpeas/hummus.

    • Base meals on vegetables, fruits, whole grains and other nutrient-rich foods.

    • Prefer sustainable dietary and activity changes over fad diets.

    Exam note: These calculations reproduce the lecture's simplified model. Actual weight change varies, and large calorie deficits may be inappropriate for some people.

    Rapid-recall checklist

    Recall progress

    0/10

    Healthy diet: characteristics and benefits

    EAR vs RDA vs AI vs UL

    EER vs AMDR and adult macronutrient ranges

    Calculate carbohydrate and fat calories from total kcal

    Moderation vs nutrient density vs energy density

    Traditional food-pyramid servings

    Six food-exchange groups and their purpose

    Mediterranean vs Emirati vs planetary health diets

    BMI vs waist-to-hip ratio vs body-fat percentage

    Weight-loss calorie calculations and sustainable habits

    Reset checklist

NUTRITION ASSESMENT

1. What is nutritional assessment, why is it performed, and what are the direct vs indirect methods?

2. What anthropometric measurements assess nutritional status, and what are their key interpretations?

3. What are the key anthropometric formulas and obesity-risk cut-offs?

4. What are the important biochemical tests used in nutritional assessment?

5. Compare the advantages and limitations of anthropometric, biochemical and clinical assessment.

6. — Which nutritional deficiencies have characteristic clinical signs?

7. What dietary-history methods are used, and how do qualitative and quantitative dietary assessments differ?

8. What is protein-energy malnutrition (PEM), and how do the Wellcome and Gomez classifications differ?

9. — Differentiate kwashiorkor from marasmus.

10. How is severe PEM assessed, treated and prevented, and what complications must be recognised?

Height = 5'4" female

Weight = 60 kg

IBW:

45.5+(2.3×4)=54.7kg45.5 + (2.3 \times 4)=54.7kg45.5+(2.3×4)=54.7kg

30% above IBW:

54.7×1.3=71.1kg54.7 \times 1.3 = 71.1kg54.7×1.3=71.1kg

Actual weight = 60 kg

60 < 71.1 ❌

So:

Dietary History: Most common procedures used

Disadvantages

Patients may hoard food which is

recorded as eaten

People can remember meals but often

forget snacks

1) Food choices often change during

recording periods

2) Inaccurate estimates of actual

quantity of food consumed

May significantly underestimate usual

intakes

According to the treatment protocol for Protein-Energy Malnutrition (PEM) outlined in the lecture, what is the recommended dietary energy support per kilogram of body weight per day? 200CAL

What is the formula provided in the lecture for estimating Mid-Arm Muscle Circumference (MAMC)?

An estimate of lean body mass = AC (in Cm) – (0.314X TSF (mm))

1. Answer:

   Nutritional assessment evaluates an individual's nutritional needs using biochemical, anthropometric, physical and dietary data to determine appropriate nutritional intake.

   Purpose:

   ·        Identify individuals or populations at risk of malnutrition or already malnourished.

   ·        Develop healthcare programs based on community needs.

   ·        Evaluate the effectiveness of nutritional interventions.

   Direct methods — ABCD:

   ·        A: Anthropometric measurements.

   ·        B: Biochemical/laboratory measurements.

   ·        C: Clinical/physical assessment.

   ·        D: Dietary evaluation.

   Indirect methods: Ecological variables (crop production), economic factors (income and food availability/prices), cultural and social habits, and vital health statistics (morbidity, mortality, infant/under-five mortality and fertility indices).

2. Answer:

   ·        Height/length and weight: Assess growth, wasting and overweight.

   ·        BMI: Weight (kg) ÷ height² (m²).

   ·        Head circumference/chest circumference ratio: CC/HC below 1 in children under 2 years suggests wasting, according to the lecture.

   ·        Skinfold thickness (TSF): Estimates subcutaneous fat.

   ·        Arm circumference (AC) and mid-arm muscle circumference (MAMC): Assess body composition and muscle reserves.

   ·        Waist circumference, waist-to-hip ratio and waist-to-height ratio: Assess central obesity and associated metabolic risk.

   ·        Bioelectrical impedance analysis (BIA): Estimates body fat, lean body mass and total body water; advanced devices can assess phase angle.

   Growth terminology:

   ·        Stunting: Low height-for-age; usually reflects chronic malnutrition.

   ·        Wasting: Low weight-for-height; suggests acute/current undernutrition.

   ·        Underweight: Low weight-for-age.

3. Answer:

   BMI:

   \[ \text{BMI}=\frac{\text{Weight (kg)}}{\text{Height (m)}^2} \]

   Mid-arm muscle circumference (MAMC):

   \[ \text{MAMC (cm)}=\text{AC (cm)}-0.314\times\text{TSF (mm)} \]

   Ideal body weight (IBW), adults ≥18 years and height ≥60 inches:

   ·        Males: \(50+2.3\times\) each inch above 5 feet (in kg).

   ·        Females: \(45.5+2.3\times\) each inch above 5 feet (in kg).

   Adjusted body weight (ABW): Used in the lecture when actual weight is more than 30% above calculated IBW.

   \[ \text{ABW}=\text{IBW}+0.4(\text{Actual weight}-\text{IBW}) \]

   Waist-to-hip ratio (WHR):

   ·        Women: \(>0.85\) indicates high risk.

   ·        Men: \(>0.90\) indicates high risk.

   Waist-to-height ratio: \(>0.5\) indicates central obesity and increased diabetes/CVD risk, according to the lecture.

4. Answer:

   Test	Key interpretation
   Creatinine height index (CHI)	Estimates muscle depletion using 24-hour urinary creatinine relative to expected excretion for height
   Urinary urea nitrogen (UUN)	Assesses protein catabolism and protein balance
   Albumin, transferrin/TIBC, thyroxine-binding prealbumin, retinol-binding protein	Visceral proteins; nonspecific indicators influenced by their half-lives
   Blood urea nitrogen (BUN)	Can help assess protein intake during nutritional support, especially when serum creatinine is normal
   Serum creatinine	Below 0.6 mg/dL may indicate muscle wasting; increased levels may occur in renal failure or dehydration
   Prothrombin time	Prolongation may indicate vitamin K deficiency
   Red blood cell parameters	Help investigate anaemia

   CHI formula:

   \[ \text{CHI}=\frac{\text{24-h urinary creatinine}\times100}{\text{Expected 24-h creatinine for height}} \]

   ·        \(>80\%\): Normal

   ·        \(60–80\%\): Mild protein depletion

   ·        \(40–60\%\): Moderate depletion

   ·        \(<40\%\): Severe depletion

5. Answer:

   ·        Anthropometric: Objective, reproducible, inexpensive and requires minimal training. Limitations include inter-observer errors, uncertain reference standards, arbitrary cut-offs and limited diagnostic specificity.

   ·        Biochemical: Precise, reproducible and can detect early changes before clinical signs appear; helps validate dietary data. Limitations include cost, time, specialist training and laboratory facilities.

   ·        Clinical/physical: Fast, inexpensive and non-invasive. However, physical signs often appear after biochemical changes and are frequently nonspecific; clinical assessment alone is insufficient.

   Exam trap: No single method fully establishes nutritional status. Findings should be interpreted together.

6. Answer:

   ·        Niacin (vitamin B3) deficiency / pellagra: The four Ds — dermatitis, diarrhoea, dementia and death. Casal’s necklace is a characteristic rash around the neck.

   ·        Vitamin C deficiency / scurvy: Gingivitis, capillary fragility and petechial haemorrhages.

   ·        Iodine deficiency: Goitre, particularly in iodine-deficient regions.

   ·        Vitamin D deficiency: Rickets in children and osteomalacia in adults.

   Clinical signs can suggest a deficiency, but are not always specific enough to confirm it independently.

7. Answer:

   Methods:

   ·        24-hour dietary recall: Interview about everything eaten and drunk during the previous 24 hours; depends on memory and interviewer skill.

   ·        Food diary/record: Records foods and amounts consumed over approximately 3 days to 1 week; may include time, location and emotional state.

   ·        Food-frequency questionnaire (FFQ): Checklist of foods—often 40–80 types—used to assess frequency of consumption over an extended period.

   ·        Dietary history: Includes medical and drug history, allergies/intolerances, family and cultural background, habits, occupation, economic status and social factors.

   Interpretation:

   ·        Qualitative: Classifies foods into food groups and compares servings with recommendations.

   ·        Quantitative: Calculates energy and specific nutrient intake using food-composition tables; can be time-consuming and costly.

   Exam trap: A plate diagram is convenient but cannot accurately quantify exact nutrient intake or reliably account for complex diets and individual clinical needs

8. Answer:

   PEM is undernutrition involving inadequate energy and/or protein intake, often compounded by infection and adverse social/environmental conditions.

   Wellcome classification: Uses weight-for-age percentage of the reference standard plus oedema.

   Weight-for-age	Oedema	Classification
   60–80%	Absent	Underweight
   60–80%	Present	Kwashiorkor
   Below 60%	Absent	Marasmus
   Below 60%	Present	Marasmic-kwashiorkor

   Gomez classification: Uses weight-for-age percentage only.

   ·        Grade I (mild): 90–70%

   ·        Grade II (moderate): 70–60%

   ·        Grade III (severe): below 60%

   The lecture gives the reference as the 50th percentile/WHO chart.

   Limitation of Gomez: It does not consider height or oedema and cannot distinguish acute from chronic malnutrition.

9. Answer:

   Feature	Kwashiorkor	Marasmus
   Main description	Protein-deficiency-associated oedematous malnutrition	Severe energy and protein deficiency with starvation
   Oedema	Present	Absent
   Muscle wasting	Present	Severe
   Subcutaneous fat	Relatively conserved compared with marasmus, per lecture	Severely depleted
   Growth retardation	Present	Severe
   Hair/skin changes	Common; depigmentation and flaky-paint dermatitis may occur	Not typical in the lecture's description
   Behaviour/appetite	Psychomotor changes may occur	Often alert, miserable and hungry
   Other findings	Moon face, anaemia; sometimes hepatomegaly and cardiomyopathy	May have diarrhoea and dehydration

   High-yield distinction: Oedema strongly points toward kwashiorkor; severe wasting without oedema points toward marasmus.

   Kwashiorkor is multifactorial—not solely dietary—and often occurs in the second year of life following abrupt weaning.

10. Answer:

    Assessment/investigations:

    ·        Detailed history, dietary assessment and physical examination.

    ·        Anthropometry and growth monitoring.

    ·        Full blood count, blood glucose, electrolytes, calcium/phosphate and serum proteins.

    ·        Stool/urine tests for parasites and infection; septic screening.

    ·        Evaluate for HIV and malabsorption when indicated; further tests depend on the clinical picture.

    Major complications:

    ·        Hypoglycaemia and hypothermia.

    ·        Hypokalaemia and hyponatraemia.

    ·        Infection, dehydration and shock.

    ·        Heart failure.

    Management principles in the lecture:

    ·        Correct fluid and electrolyte disturbances.

    ·        Treat infections and worm infestations.

    ·        Provide progressive nutritional rehabilitation/refeeding, vitamins and minerals.

    ·        Prevent hypothermia; use frequent small feeds and continue breastfeeding where appropriate.

    ·        The lecture gives a nutritional-support target of 3–4 g protein and 200 kcal/kg/day; this is a lecture figure, not a universal starting prescription for every severely malnourished child.

    ·        Counsel caregivers, support follow-up, immunisation and prevention of recurrence.

    Prevention: Nutrition education, balanced diets, safe food and water, breastfeeding, regular growth monitoring and vaccination.

    Rapid-recall checklist

    Recall progress

    0/10

    Direct vs indirect nutritional assessment; ABCD

    Anthropometric indices: stunting, wasting, underweight, BIA

    BMI, MAMC, IBW/ABW and central-obesity cut-offs

    CHI formula and interpretation; UUN, visceral proteins and other labs

    Advantages and limitations of assessment methods

    Pellagra, scurvy, iodine and vitamin D deficiency signs

    24-hour recall vs food diary vs FFQ; qualitative vs quantitative

    Wellcome vs Gomez PEM classification

    Kwashiorkor vs marasmus

    PEM investigations, complications, treatment and prevention

LIFE CYCLE

1. What is life-course nutrition, and why is nutrition important across different life stages?

2. — What are the nutritional priorities before and during pregnancy?

3. — What are the energy requirements, weight-gain recommendations and red flags during pregnancy?

4. Which nutrients are especially important during pregnancy, and how can common pregnancy-related problems be managed?

5. What is the Barker hypothesis, and what are the nutritional requirements during lactation?

6. What are the benefits of breastfeeding, its contraindications listed in the lecture, and the key Baby-Friendly Hospital Initiative steps?

7. What are the nutritional requirements and feeding milestones during infancy?

8. — What are the key nutritional priorities and problems in toddlers, preschool children, school-age children and adolescents?

9. What are the nutritional concerns in adulthood and older age?

10. — Can you match each life stage with its main nutritional priorities?

. Fetal Origins of Adult Disease” (FOAD): noted that low birth weight (LBW) serves as proxy not just for fetal, but also adult healt

(A woman starting pregnancy at a normal weight should gain a total of 25–35 lbs).

During the second trimester, an extra 340 calories daily are recommended

A Large-for-Gestational-Age (LGA) infant is defined as having a weight greater than the 90th percentile for gestational age

n the MUST tool, an acute disease score of 2 is assigned if there is likely to be no nutritional intake for >5 days

An extra 330 kcal is recommended during the first 6 months of lactation.

n overall MUST score of 2 or more indicates High Risk, requiring treatment and referral to a dietitian

1. Answer:

   Life-course nutrition is the study and application of nutritional principles across preconception, pregnancy, lactation, infancy, childhood, adolescence, adulthood and older age.

   Nutritional requirements change with age, growth, physical activity, pregnancy/lactation, physiological changes and disease.

   ·        Undernutrition: stunting, wasting, underweight and micronutrient deficiencies.

   ·        Overnutrition: overweight, obesity and excess energy intake.

   ·        Double burden of malnutrition: undernutrition, micronutrient deficiencies and overweight/obesity can coexist within the same population.

   Key concept: Poor maternal nutrition → impaired fetal growth → low birth weight → increased vulnerability and potential chronic disease risk later in life.

2. Answer:

   Preconception:

   ·        Maintain healthy body weight and dietary patterns.

   ·        Ensure adequate folate, iron and iodine.

   ·        Correct nutritional deficiencies and manage chronic diseases.

   ·        Avoid excessive alcohol.

   Pregnancy: Additional nutrients and energy support fetal growth, placental development, maternal tissue expansion, increased blood volume and preparation for lactation.

   Folic acid: The lecture recommends 400 micrograms daily, beginning 1–3 months before conception and continuing through the first 6 weeks of gestation, to reduce neural tube defect risk.

   Other important nutrients:

   ·        Iron: maternal red-cell mass, fetal needs and placental development.

   ·        Iodine: thyroid hormone production and fetal neurodevelopment.

   Calcium and vitamin D: skeletal development, bone health and calcium metabolism

3. Answer:

   The lecture gives these approximate daily energy intakes for an average-size woman with average activity:

   ·        Nonpregnant: 2,200 kcal/day

   ·        Pregnant: 2,500 kcal/day

   ·        Lactating: 2,700 kcal/day

   Pregnancy-specific additional energy:

   ·        First trimester: no additional calories.

   ·        Second trimester: approximately 340 kcal/day extra.

   ·        Third trimester: approximately 450 kcal/day extra.

   Weight gain:

   ·        First trimester: 1–4 lb total.

   ·        Second and third trimesters: approximately 2–4 lb/month.

   ·        Gain should be individualized according to prepregnancy nutritional status and clinical guidance.

   Red flags from the lecture:

   ·        Inadequate gain: less than 1 kg/month during the first and second trimesters.

   ·        Excessive gain: greater than 3 kg/month.

   ·        Sudden gain of 3–5 lb in one week may indicate fluid retention.

   Maternal obesity increases the risk of hypertension, gestational diabetes and a large-for-gestational-age infant.

   Exam trap: “Eating for two” does not mean doubling food intake.

4. Answer:

   Fibre: The lecture recommends 25–35 g/day. Whole grains, fruits and vegetables help prevent constipation and support metabolic health.

   Iron: The lecture gives 15 mg/day during childbearing years. Deficiency can cause maternal anaemia and is associated with adverse maternal and fetal outcomes, including prematurity and low birth weight.

   Avoid or discuss with a healthcare provider: Alcohol, cigarettes, recreational drugs, over-the-counter medicines, herbal supplements and caffeine.

   Common problems:

   ·        Nausea/vomiting: Avoid strong odours and an empty stomach; eat slowly and try small, frequent meals.

   ·        Constipation: Increase fibre, drink adequate water and remain physically active; avoid unsupervised laxatives.

   ·        Heartburn: Eat smaller meals, avoid lying down after eating and elevate the head of the bed.

   ·        Pica: Craving non-food substances such as clay, dirt, ice or laundry starch. It may be associated with iron-deficiency anaemia, malnutrition or lead exposure.

5. Answer:

   Barker hypothesis / fetal origins hypothesis: The fetal environment can influence the risk of chronic diseases in adult life. Fetal adaptations to undernutrition may contribute to later disease risk, and low birth weight is discussed in the lecture as a marker of fetal and later-life health.

   Lactation requirements from the lecture:

   ·        Additional energy: 330 kcal/day during the first 6 months and 400 kcal/day during the second 6 months.

   ·        Protein: an additional 25 g/day, or approximately 70 g/day total based on 1.1 g/kg/day of maternal weight.

   ·        Vitamin D: 400 IU/day.

   ·        Drink according to thirst and keep fluids available during breastfeeding.

   Adequate energy, protein, iodine, vitamin B12 when intake is inadequate, vitamin D considerations and overall dietary quality are important.

6. Answer:

   Benefits: Breastfeeding is associated with reduced incidence and severity of infectious diseases and lower rates of some other conditions, including asthma, coeliac disease, food allergies and type 1 and type 2 diabetes, as described in the lecture.

   Feeding recommendations: Exclusive breastfeeding for the first 6 months; WHO encourages continuation through the second year of life.

   Contraindications listed in the lecture:

   ·        Classic galactosaemia in the infant.

   ·        Active untreated tuberculosis.

   ·        Brucellosis.

   ·        Maternal chemotherapy with certain agents.

   ·        Maternal HIV.

   ·        Active herpes simplex.

   Clinical caveat: Some contraindications depend on local guidance, treatment, affected breast and individual circumstances; maternal HIV guidance, in particular, varies by setting. Follow current clinical protocols rather than treating this lecture list as universal.

   Baby-Friendly Hospital Initiative: Written breastfeeding policies, staff training, prenatal education, early initiation, practical feeding support, avoiding unnecessary supplements, rooming-in, feeding on demand, avoiding artificial teats/pacifiers when appropriate, and connecting mothers with breastfeeding support groups.

7. Answer:

   Infancy (0–1 year) involves rapid growth, brain development and high energy needs relative to body size.

   ·        Energy: approximately 98–108 kcal/kg/day according to the lecture.

   ·        Birth weight doubles by 6 months and triples by 1 year.

   ·        Length increases by approximately 50% during the first year.

   ·        Breast milk or iron-fortified infant formula forms the basis of the diet.

   ·        Vitamin D supplementation may be needed; the lecture particularly mentions breastfed infants.

   ·        Introduce iron-fortified cereal at approximately 6 months.

   Complementary foods:

   ·        Introduce at around 4–6 months according to the lecture, based on developmental readiness.

   ·        Look for good head and neck control and interest in food.

   ·        Introduce one food at a time and repeatedly offer new foods.

   The lecture lists honey, egg whites, orange juice and cow’s milk as foods to avoid during the first year. Cow’s milk should not be used as the main drink before 12 months; modern guidance on egg introduction differs from the lecture’s blanket avoidance.

   Exam trap: All infants, whether breastfed or formula-fed, may need vitamin D supplementation.

8. Answer:

   Toddlers and preschool children (approximately 1–3 years for toddlers):

   ·        Encourage varied foods and balance intake with physical activity.

   ·        Ensure adequate protein, iron, calcium, vitamin D and zinc.

   ·        Limit excess sugar, salt and unhealthy fats.

   School-age children:

   ·        Growth rate slows, so energy requirements per unit of body weight decline.

   ·        The lecture gives approximately 85 kcal/kg/day.

   ·        Encourage breakfast, healthy snacks and nutrition education.

   Preventing childhood obesity:

   ·        Prefer water over sugary drinks.

   ·        Offer nutrient-dense meals and snacks.

   ·        Reduce sedentary behaviour and mindless snacking.

   ·        Encourage at least 60 minutes of daily physical activity.

   Adolescents:

   ·        Rapid growth, puberty, bone formation and increased muscle mass raise nutrient needs.

   ·        Pay particular attention to calcium, iron and vitamin D.

   ·        Risks include obesity, atherosclerosis, hypertension, anorexia nervosa and bulimia nervosa.

   ·        Eating behaviours are influenced by peers, family modelling, food availability, cost, culture, media and body image.

9. Answer:

   Adulthood: Focus on healthy body weight, adequate nutrient intake and prevention of chronic disease.

   Older adults: Often have lower energy requirements but higher risk of nutrient inadequacy due to reduced appetite, altered taste/smell, dental problems, dysphagia, chronic disease, polypharmacy and social isolation. Nutrient density becomes particularly important.

   Key concerns:

   ·        Sarcopenia: Age-related loss of muscle mass, strength and physical performance; associated with inadequate protein intake, inactivity, chronic disease and ageing.

   ·        Dehydration: Reduced thirst, impaired renal concentrating ability, difficulty accessing fluids, cognitive impairment and swallowing difficulties.

   ·        Vitamin B12: Absorption may decline with age or certain medications.

   ·        Vitamin D and calcium: Important for bone health.

   ·        Iron: Deficiency warrants investigation for underlying causes rather than assuming poor intake.

   ·        Fibre: Helps prevent constipation.

   Older adults are also more vulnerable to foodborne illness. The lecture advises avoiding raw/undercooked animal products, unpasteurised milk and soft cheeses, unwashed produce, and deli meats/hot dogs that have not been reheated.

10. Answer:

    Life stage	Main priorities
    Preconception	Folate, healthy weight, micronutrient adequacy
    Pregnancy	Iron, folate, iodine, calcium, vitamin D and adequate energy
    Lactation	Adequate energy, protein and micronutrients for maternal health and milk production
    Infancy	Breast milk/formula, iron, vitamin D and complementary feeding
    Childhood	Growth, protein, iron, calcium and healthy dietary patterns
    Adolescence	Growth, iron, calcium, vitamin D and healthy eating behaviours
    Adulthood	Healthy weight and chronic disease prevention
    Older age	Nutrient density, protein, hydration, vitamin B12, vitamin D, calcium and prevention of malnutrition

    Key principle: Nutritional needs are stage-specific, and nutrition at one stage can influence health throughout the life course.

    Rapid-recall checklist

    Recall progress

    0/10

    Life-course nutrition, double burden and first 1,000 days

    Preconception priorities and folic acid timing/dose

    Pregnancy calories, weight gain and red flags

    Iron, iodine, calcium, vitamin D, fibre and pica

    Barker hypothesis and lactation requirements

    Breastfeeding benefits, contraindications and hospital initiative

    Infant growth, energy needs, vitamin D and complementary feeding

    Childhood/adolescent needs and obesity prevention

    Older-age nutrition, sarcopenia and dehydration

    Match each life stage to its nutritional priorities

ESTIMATING INDUVVISUAL ENERGY

1. What are the fuel factors, and how is total energy expenditure (TEE) calculated?

2. What are BMR, BEE, REE, and RMR? Which component of TEE is most variable?

3. What is the gold standard for measuring resting energy expenditure, and what are its limitations?

4. : How do you estimate energy requirements using rules of thumb and activity factors?

5. Q: What are the Harris–Benedict equations, and how are activity and stress factors applied?

6. : What are ideal body weight (IBW), percentage of IBW, and adjusted body weight formulas?

7. : How do you calculate BMI, and what is a MET?

8. What are the adult protein requirements, nitrogen balance formula, and interpretation?

9. What are the calorie-to-nitrogen ratios associated with different metabolic states?

10. What are the AMDRs, and how do you calculate each macronutrient’s daily requirement?

11. Categorize PA level (PAL) according to standard values – 1.2: Chair or bed bound – 1.4-1.5: Sedentary– 1.6-1.7: Very light– 1.8-1.9: Moderate – 2.0-2.4: Heavy

12. The Ireton-Jones Equation is specifically noted for spontaneous and ventilator-dependent hospitalized and critically ill patients).

13. A factor of 4 is added to nitrogen output to account for losses via stools, sweat, and wounds

14. Infants and children weighing 1–10 kg require 100–150 mL/kg of daily fluid.

15. 1. Resting Energy Expenditure (REE) Prediction Equations (Harris-Benedict, Mifflin-St. Jeor, Ireton-Jones)

    • What they entail: They estimate how many calories a body burns at rest (Basal/Resting Metabolic Rate) using baseline biological variables: weight, height, age, and gender.

    • The Clinical Takeaway: Different equations are tailored to different populations. For instance, Mifflin-St. Jeor is typically used for healthy or non-hospitalized individuals, whereas specialized equations like Ireton-Jones are built for ventilated, trauma, or critically ill patients.

    2. Activity and Stress/Injury Factors (AF & IF)

    • What they entail: Because nobody just lies completely flat and completely still all day (except under basal conditions), baseline energy expenditure must be scaled up to match real-world energy demands.

    • The Clinical Takeaway:

      • Activity Factors (AF): Scale energy up based on movement or being bedbound (e.g., bedbound vs. moderately active).

      • Stress/Injury Factors (IF): Account for hypermetabolic states caused by surgery, skeletal trauma (bone fractures), fever (adding roughly 10% or $\times 1.1$ per degree Fahrenheit), or severe burns (which can skyrocket energy needs up to $\times 2.1$).

    3. Nitrogen Balance

    • What they entail: It tracks protein status by looking at Nitrogen Intake minus Nitrogen Output ($\text{Intake} - \text{Output}$). Since protein is roughly 16% nitrogen, dividing total protein intake by 6.25 gives nitrogen intake.

    • The Clinical Takeaway:

      • Positive balance means anabolism/growth/healing (taking in more than you lose).

      • Negative balance means catabolism/muscle wasting.

      • The constant "+ 4" added to the output accounts for unmeasured nitrogen losses through sweat, stool, and wounds.

    4. Fluid Requirements

    • What they entail: Estimating the volume of water a patient needs to prevent dehydration, mapped either to their total caloric expenditure (~1 mL per kcal) or scaled tier-by-tier by body weight.

    • The Clinical Takeaway: Fluid needs change drastically across the life cycle and clinical state. For example, infants and children have a drastically higher fluid requirement per kg (100–150 mL/kg) compared to older adults over 65 (25 mL/kg) due to body composition and metabolic differences.

16. Matching Scenarios to Equations: Instead of calculating a number, a question might ask: "Which predictive equation is most appropriate for a mechanically ventilated, critically ill trauma patient?" (Answer: You’d know it’s the Ireton-Jones equation because it accounts for trauma/burns and ventilation).

17. Understanding Modifiers & Multipliers: He might test whether you know why energy needs change. For example: "How do severe burns or a high fever impact a patient's baseline energy expenditure?" (You’d know burns dramatically skyrocket needs—up to a factor of 2.1—and fever adds roughly 10% or $\times 1.1$ per degree Fahrenheit).

18. Interpreting Clinical Status: Instead of calculating nitrogen balance down to the decimal, a question might describe a patient with a heavily negative nitrogen balance and ask what that indicates (catabolism, muscle breakdown, or inadequate protein support).

19. Population Rules of Thumb: Knowing when to apply certain guidelines, such as why infants have massively higher fluid requirements per kilogram (100–150 mL/kg) compared to older adults. Infants have higher metabolic rates, greater body surface area relative to weight, and immature renal concentrating ability

20. The constant of +4 added to nitrogen output specifically accounts for unmeasured nitrogen losses through stools, sweat, and wounds).

    • 
      

    
    

1. A:

   ·        Carbohydrate = 4 kcal/g

   ·        Protein = 4 kcal/g

   ·        Fat = 9 kcal/g

   ·        Alcohol = 7 kcal/g

   TEE = BEE + physical activity + thermic effect of food (DIT).

   ·        Intake > output → weight gain.

   ·        Intake < output → weight loss.

   ·        DIT is approximately 10% of energy expenditure after a mixed meal; protein has a greater thermic effect than fat or carbohydrate.

2. A:

   ·        BMR/BEE: Energy required for essential physiological functions at rest under standardized conditions; approximately 60–70% of TEE.

   ·        REE: Similar to BMR but measured under less stringent conditions; often estimated using equations.

   ·        RMR: Resting metabolic rate.

   ·        Fat-free mass is one of the strongest determinants of resting energy expenditure.

   ·        Physical activity is the most variable component, typically 25–50% of TEE.

   Exam trap: Prediction equations estimate energy needs; they do not directly measure them.

3. A: Indirect calorimetry.

   ·        Measures oxygen consumption (\(VO_2\)) and carbon dioxide production (\(VCO_2\)).

   ·        Converts these measurements into REE/RMR using equipment software.

   ·        Limitations: expensive, sophisticated equipment, trained personnel, sensitivity to measurement error, and need for controlled measurement conditions.

   The lecture states that nutrition support is recommended at 100% of measured RMR.

4. A:

   Group/activity	Lecture estimate
   Men	1 kcal × weight (kg) × 24
   Women	0.9 kcal × weight (kg) × 24
   Children under 6 months	120 kcal/kg/day
   Children 6–12 months	110 kcal/kg/day

   TEE ≈ REE × physical activity level (PAL).

   PAL	Category
   1.2	Chair- or bed-bound
   1.4–1.5	Sedentary
   1.6–1.7	Very light
   1.8–1.9	Moderate
   2.0–2.4	Heavy

   Remember: These are estimates; requirements depend on age, body composition, illness, activity, nutritional status, and metabolic state.

5. A: The lecture gives these equations for BEE:

   ·        Male: \(66.5 + 13.7W + 5.0H - 6.8A\)

   ·        Female: \(655 + 9.6W + 1.8H - 4.7A\)

   \(W\) = weight in kg; \(H\) = height in cm; \(A\) = age in years.

   Then:

   Final estimated energy = BEE × activity factor × injury/stress factor, when both factors are indicated.

   Examples from the lecture:

   ·        Bed most of the time: activity factor 1.2

   ·        Ambulatory/moderately active: 1.3

   ·        Very active: 1.5

   ·        After surgery: stress factor 1.2

   ·        Skeletal trauma: 1.35

   ·        Severe burns: 2.1

   Fever and other trauma may increase requirements; the lecture lists a fever factor of 1.1 per °F, which should be interpreted cautiously rather than applied blindly.

6. A: Hamwi formula:

   ·        Women: 100 lb for the first 5 ft + 5 lb per inch above 5 ft.

   ·        Men: 106 lb for the first 5 ft + 6 lb per inch above 5 ft.

   ·        Small frame: subtract 10%; large frame: add 10%.

   ·        Below 60 inches: subtract 5 lb for each inch below 60 inches.

   \[ \%\text{IBW}=\frac{\text{Actual weight}}{\text{IBW}}\times100 \]

   The lecture gives adjusted body weight (AdjBW) for patients substantially above IBW:

   \[ \text{AdjBW}=\text{IBW}+0.4(\text{Actual weight}-\text{IBW}) \]

   It describes using AdjBW above 125% of IBW as controversial.

7. A:

   \[ \text{BMI}=\frac{\text{Weight (kg)}}{\text{Height (m)}^2} \]

   Lecture example: 97.5 kg and 1.651 m gives BMI ≈ 35.7 kg/m², classified as obesity.

   ·        1 MET = energy expenditure while sitting quietly.

   ·        Approximately 3.5 mL O₂/kg/min.

   For an average 70-kg adult, approximately 1.2 kcal/min, according to the lecture

8. A:

   ·        Healthy adults: 0.8 g protein/kg/day.

   ·        Metabolic stress, trauma, or disease: 1.0–1.5 g/kg/day in the lecture.

   \[ \text{Nitrogen balance}=\text{Nitrogen intake}-\text{Total nitrogen output} \]

   \[ \text{Nitrogen intake}=\frac{\text{Protein intake (g/day)}}{6.25} \]

   \[ \text{Nitrogen balance}=\frac{\text{Protein intake}}{6.25}-\text{UUN}-4 \]

   UUN = urinary urea nitrogen; the additional 4 g estimates other nitrogen losses.

   ·        Positive balance → nitrogen retained; supports anabolism.

   ·        Negative balance → nitrogen loss/catabolism.

   ·        Lecture target for anabolism: net positive balance of 2–4 g/day.

9. A:

   Calorie-to-nitrogen ratio	Lecture association
   200:1	Healthy
   150:1	Anabolism
   125:1	Diabetes mellitus or sepsis
   100:1	Trauma

   Example: A patient consuming 1,920 kcal and 60 g protein has nitrogen intake of \(60/6.25=9.6\) g/day.

   \[ 1920 \div 9.6 = \mathbf{200:1} \]

   Exam trap: Calculate nitrogen intake from protein first, then divide total calories by nitrogen intake.

10. A: Lecture AMDRs:

    Macronutrient	AMDR	Lecture goal
    Carbohydrate	45–65%	60%
    Fat	20–35%	25%
    Protein	10–35%	15%

    Calculation method:

    1.     Multiply total daily kcal by the desired percentage.

    2.     Divide by the fuel factor to obtain grams.

    For a 2,000-kcal diet using the lecture goals:

    ·        Carbohydrate: \(2000 \times 0.60 \div 4=\) 300 g/day

    ·        Fat: \(2000 \times 0.25 \div 9\approx\) 55.6 g/day

    ·        Protein: \(2000 \times 0.15 \div 4=\) 75 g/day

    Check: The percentages total 100%, and the calculated grams provide approximately 2,000 kcal.

    Rapid-recall checklist

    Fuel factors: 4 / 4 / 9 / 7 kcal per gram

    TEE = BEE + activity + DIT

    Indirect calorimetry measures VO₂ and VCO₂

    Know the Harris–Benedict equations and units

    Apply activity and stress factors carefully

    Know Hamwi IBW and percentage of IBW formulas

    BMI = kg/m²; 1 MET ≈ 3.5 mL O₂/kg/min

    Nitrogen intake = protein ÷ 6.25

    Nitrogen balance = intake − output

    Calculate AMDR percentages in kcal, then convert to grams

    0 of 10 reviewed

Here is your ultra-high-yield cheat sheet for Estimating Individual Energy and Nutrient Needs to review right before your exam:

1. Components of Total Energy Expenditure (TEE)

• Basal Energy Expenditure (BEE) / BMR: Accounts for 60%–75% of TEE; supports breathing, circulation, and core organ function. It falls slowly with age due to muscle loss.

  
  

• Physical Activity: Accounts for 15%–30% of TEE and is the most variable component.

  
  

• Thermic Effect of Food (Diet-Induced Thermogenesis / DIT): Accounts for ~10% of TEE; the energy needed to process food (protein has the highest thermic effect).

  
  

2. Fuel Factors (Energy Density)

• Carbohydrate: $4 \text{ kcal/g}$

  
  

• Protein: $4 \text{ kcal/g}$

  
  

• Fat: $9 \text{ kcal/g}$

  
  

• Alcohol: $7 \text{ kcal/g}$

  
  

3. Measuring vs. Predicting Energy Requirements

• Gold Standard Measurement: Indirect calorimetry measures oxygen consumption ($VO_2$) and carbon dioxide production ($VCO_2$).

  
  

• Prediction Equations (Clinical Estimates):

  
  
  

  • Harris-Benedict & Mifflin-St. Jeor: Used to predict Resting Metabolic Rate (RMR/REE) based on weight, height, age, and gender.

    
    

  • Ireton-Jones Equation: Specifically utilized for spontaneous and ventilator-dependent or critically ill hospitalized patients.

    
    

4. Activity and Stress (Injury) Multipliers

• Activity Factors (TEE = BEE $\times$ AF):

  
  
  

  • Bed-bound / Chair-bound: $\times 1.2$

    
    

  • Ambulatory / Moderately active: $\times 1.3$

    
    

  • Very active: $\times 1.5$

    
    

• Stress/Injury Factors (TEE = BEE $\times$ IF):

  
  
  

  • Post-surgery: $\times 1.2$

    
    

  • Skeletal trauma (bone fractures): $\times 1.35$

    
    

  • Fever: $\times 1.1$ for each degree Fahrenheit

    
    

  • Severe burn: $\times 2.1$

    
    

5. Protein Needs & Nitrogen Balance

• Nitrogen Balance Formula: $\text{Nitrogen Balance} = \text{Intake} - \text{Output} = (\text{Protein (g)/6.25}) - \text{UUN} - 4$ (where 4 accounts for non-urinary losses via stool, sweat, and wounds).

  
  

• Adult RDA: $0.8 \text{ g/kg}$ (increases to $1.0 - 1.5 \text{ g/kg}$ during metabolic stress, trauma, or disease).

  
  

• Calorie-to-Nitrogen Ratios:

  
  
  

  • Healthy = 200:1

    
    

  • Anabolism = 150:1

    
    

  • Diabetes / Sepsis = 125:1

    
    

  • Trauma = 100:1

    
    

6. Fluid Requirement Methods

• Method 1 (Energy-based): $1 \text{ mL}$ of fluid per $\text{kcal}$ consumed.

  
  

• Method 2 (Weight-based):

  
  
  

  • Average adult (16–55 yrs): 30–35 mL/kg.

    
    

  • Older adult ($55-65 \text{ yrs}$): 30 mL/kg.

    
    

  • Elderly adult ($>65 \text{ yrs}$): 25 mL/kg.

ENTERAL NUTRITION

1. What is the key principle when choosing between enteral and parenteral nutrition?

2. What are the main indications and contraindications for EN?

3. . Q: Differentiate NG, NJ, gastrostomy/PEG, and jejunostomy/PEJ feeding.

4. : What are bolus and continuous enteral feeding, and how do you reduce aspiration risk?

5. What are the main complications of EN, and how is tube patency maintained?

6. : When is PN indicated, and how do PPN, CPN, partial PN, and TPN differ?

7. What are the main venous access options for PN, and what complications must be monitored?

8. What is refeeding syndrome, and why is it dangerous?

9. What safety and monitoring principles are essential for patients receiving PN?

10. A patient has a functional gut but cannot swallow safely. Another patient has intestinal obstruction and cannot be adequately nourished enterally. Which route is preferred for each?

Larger central veins allow the delivery of higher concentrations of nutrients and higher osmolarity solutions.

Mechanical obstruction or prolonged ileus of the GI tract are explicit contraindications for enteral nutrition

Tunneled Central Venous Catheters are designed for long-term use with a subcutaneous track and Dacron cuff

eeding tubes should be flushed with 30 mL of water before/after medication or when hanging fresh formula)

1. : If the gastrointestinal (GI) tract is functional and usable, prefer enteral nutrition (EN).

   ·        EN: Nutrients delivered through the GI tract when oral intake is inadequate but the gut can digest and absorb nutrients.

   ·        PN: Nutrients delivered intravenously when oral/enteral nutrition cannot meet requirements or the GI tract cannot be used adequately.

   ·        Malnutrition can result from reduced intake, increased metabolic requirements, malabsorption, severe illness, trauma, or surgery.

   EN helps preserve gut mucosa and flora, supports immune function, costs less, and avoids many IV-line complications.

2. A:

   Indications: Inadequate oral intake with a usable GI tract, including dysphagia, neurological swallowing impairment, postoperative nutritional needs, selected cancer patients, burns, trauma, sepsis, and other conditions preventing adequate oral intake.

   Contraindications or situations where EN may be unsuitable, according to the lecture:

   ·        Mechanical intestinal obstruction.

   ·        Prolonged ileus or failure of peristalsis.

   ·        Significant intestinal ischemia.

   ·        GI hemorrhage.

   ·        Intractable vomiting or severe GI intolerance.

   ·        Severe enterocolitis.

   ·        Insufficient intestinal absorptive capacity or inability to access/use the GI tract safely.

   Exam trap: Malnutrition alone does not automatically mean PN. First assess whether the GI tract can be used.

3. A:

   Route	Placement	Typical use
   NG	Nose → stomach	Short-term feeding; often around 30 days or less
   NJ	Nose → jejunum	Impaired gastric emptying/dysfunction; selected patients with aspiration risk
   Gastrostomy/PEG	Through abdominal wall → stomach	Long-term feeding when gastric function is suitable
   Jejunostomy/PEJ	Through abdominal wall → jejunum	Long-term feeding when gastric feeding is inappropriate

   ·        NG: easy to insert, but can cause discomfort, displacement, injury, and aspiration.

   ·        NJ: bypasses the stomach but is harder to place; displacement and aspiration remain possible.

   ·        Gastrostomy: requires suitable gastric function and emptying.

   ·        Jejunostomy: useful when gastric feeding is unsuitable; smaller-bore tubes may block more easily.

4. A:

   ·        Bolus feeding: Smaller volumes at set intervals, delivered by syringe or gravity. The lecture describes up to 500 mL over a maximum of 2 hours; avoid administering too quickly.

   ·        Continuous feeding: Slow, pump-controlled delivery when a slower rate improves tolerance.

   Aspiration prevention:

   ·        Position the patient appropriately and elevate the head of the bed when indicated.

   ·        Confirm correct tube placement.

   ·        Assess feeding tolerance.

   ·        Consider post-pyloric feeding in selected high-risk patients.

   Exam trap: Enteral feeding does not completely eliminate aspiration risk.

5. A:

   ·        GI: Nausea, vomiting, diarrhea, constipation, distension, cramping, feeding intolerance.

   ·        Mechanical: Tube displacement, blockage, nasal/esophageal irritation, injury.

   ·        Respiratory: Aspiration, aspiration pneumonitis, aspiration pneumonia.

   ·        Metabolic: Hyperglycemia, electrolyte abnormalities, fluid imbalance, refeeding syndrome.

   Tube care from the lecture:

   ·        X-ray is the most reliable method for confirming tube placement.

   ·        Flush with approximately 30 mL water when starting a fresh formula, before and after medications, and before and after feedings.

   ·        Document formula, infusion rate, volume delivered, start/stop times, and adverse events.

6. A:

   PN indications: Prolonged inability to obtain adequate nutrition through the GI tract, such as intestinal obstruction, severe intestinal failure, short bowel syndrome, severe malabsorption, or inability to meet requirements through EN.

   ·        Partial PN (PPN in the lecture's nutritional sense): Supplements oral or enteral intake.

   ·        Total PN (TPN): Provides complete nutritional support intravenously.

   ·        Peripheral PN: Uses a peripheral vein; generally short-term and limited by solution osmolarity, so it may not meet full needs.

   ·        Central PN: Uses central venous access, allowing more concentrated, higher-osmolarity solutions.

   Important distinction: Partial versus total describes the nutritional contribution; peripheral versus central describes venous access.

7. A:

   ·        Central access: Subclavian, jugular, or upper-limb veins (e.g., cephalic/basilic) can provide access to the central venous system. Femoral access is least preferred in the lecture.

   ·        Central catheter tip: Should end in the lower third of the superior vena cava or at the cavoatrial junction.

   ·        Peripheral access: Suitable only for selected short-term situations; avoid lower-limb veins according to the lecture.

   ·        Tunneled CVC: Designed for long-term use; catheter travels under the skin and may have a Dacron cuff.

   ·        Non-tunneled CVC: Typically short-term or emergency use; higher infection risk.

   Complications:

   ·        Catheter-related: bloodstream infection/sepsis, thrombosis, pneumothorax, malposition.

   ·        Metabolic: hyperglycemia, hypoglycemia after abrupt discontinuation, electrolyte and fluid abnormalities.

   ·        Hepatobiliary: hepatic steatosis, cholestasis, abnormal liver function tests.

   ·        Nutritional: vitamin, trace-element, or essential fatty acid deficiencies.

   Prevention: Appropriate site selection, ultrasound-guided insertion, maximal barrier precautions, staff training, and using a single lumen when appropriate.

8. A: Refeeding syndrome occurs when nutrition is reintroduced too rapidly after prolonged starvation or inadequate intake, causing electrolyte shifts into cells as metabolism increases.

   Key abnormalities:

   ·        Hypophosphatemia.

   ·        Hypokalemia.

   ·        Hypomagnesemia.

   ·        Thiamine (vitamin B1) deficiency.

   ·        Fluid disturbances and hyperglycemia.

   Why dangerous? Severe electrolyte depletion can impair cardiac, respiratory, neurological, and immune function, causing arrhythmias and potentially death.

   Exam clue: A severely malnourished patient develops falling phosphate, potassium, and magnesium after feeding begins → suspect refeeding syndrome.

   Management principle: Identify high-risk patients before starting nutrition, introduce feeding cautiously, and monitor electrolytes, fluid status, glucose, and clinical condition closely.

9. A:

   ·        Assess nutritional status, metabolic risks, medical history, medications, and treatment goals before initiation.

   ·        Monitor for refeeding syndrome, overfeeding, hyperglycemia/hypoglycemia, line infection, micronutrient deficiencies or toxicity, and long-term complications.

   ·        Monitor liver function and hepatobiliary complications, including steatosis and cholestasis.

   ·        PN compounding or additions must be performed by qualified personnel using aseptic techniques in an appropriate clean-room environment.

   ·        Consider solution stability, compatibility, storage, light protection, and hang time.

   Why is aseptic preparation critical? PN is an excellent medium for microbial growth; contamination can cause severe infection or death.

   PN may be ceased when oral/enteral feeding is re-established adequately, line sepsis occurs, or serious complications such as unresolved acute liver failure necessitate stopping it.

10. A:

    ·        Patient 1: Functional gut, unsafe swallowing → EN, using an appropriate feeding tube.

    ·        Patient 2: Intestinal obstruction preventing safe/adequate enteral feeding → PN may be indicated, depending on clinical assessment and duration of inadequate intake.

    Remember the overall decision pathway:

    1.     Can the patient eat safely and adequately by mouth?

    2.     If not, can the GI tract be used safely and adequately?

    3.     If yes, choose an appropriate EN route.

    4.     If the GI tract cannot be used or EN cannot meet requirements, consider PN.

    5.     For either route, assess nutritional risks, monitor complications, and reassess whether support remains necessary.

    Rapid-recall checklist

    Functional gut → prefer EN when feasible

    Know NG vs NJ vs PEG/gastrostomy vs jejunostomy

    Bolus vs continuous feeding

    Aspiration risk is reduced, not eliminated, by post-pyloric feeding

    Know EN complications and tube flushing/placement checks

    Partial vs total PN differs from peripheral vs central PN

    Central catheter complications: infection, thrombosis, pneumothorax, malposition

    Refeeding syndrome: phosphate, potassium, magnesium, thiamine, fluids, glucose

    PN requires careful aseptic preparation and monitoring

    Choose the route from gut function, safety, and ability to meet requirements

FOOD DRUG INTRACTION

1. Differentiate drug–nutrient, nutrient–drug, and drug–supplement interactions.

2. What are the major mechanisms of food–drug interactions?

3. Why is grapefruit juice clinically important, and which medications can it interact with?

4. How do dairy products and mineral supplements affect drug absorption

5. What are the important warfarin interactions involving food, alcohol, and supplements?

6. : What is the tyramine–MAOI interaction, and what is its major danger?

7. What are the major drug–nutrient deficiencies associated with commonly used medications?

8. How can malnutrition and altered body composition change drug effects?

9. Which medications can alter appetite, taste, GI function, and glucose levels?

10. Q: How can clinicians prevent and monitor clinically significant food–drug interactions?

A high-fat diet actually enhances the bioavailability of theophylline

You answered A, but the correct answer was B. As noted in your lecture slides, foods like ripe avocados, bananas, and yogurt actually contain small enough amounts of tyramine that they can generally be consumed in small quantities without triggering a severe reaction.

Caffeine and theophylline produce a synergistic effect that can heighten central nervous system stimulation and toxicity risks.

1. A:

   ·        Drug–nutrient: A medication affects nutrient absorption, metabolism, or status. Example: metformin → vitamin B12 deficiency.

   ·        Nutrient–drug / food–drug: Food or nutrients alter a medication’s absorption, action, or availability. Example: dairy calcium reduces absorption of certain antibiotics.

   ·        Drug–supplement: Herbal products or supplements alter drug effects. Example: St John’s wort can reduce the effectiveness of some medications, including oral contraceptives.

   Interactions may cause reduced efficacy, toxicity, altered nutritional status, or nutrient deficiencies.

2. A:

   ·        Absorption: Food delays gastric emptying; minerals form insoluble complexes (chelation); gastric pH changes drug dissolution; some foods increase absorption.

   ·        Metabolism: Grapefruit inhibits intestinal CYP3A4, increasing exposure to susceptible drugs.

   ·        Distribution: Hypoalbuminemia may increase the free fraction of highly protein-bound drugs.

   ·        Excretion: Dietary changes in urinary pH can alter renal elimination of certain weak acids and bases.

   Exam trap: Pharmacokinetics = what the body does to the drug; pharmacodynamics = what the drug does to the body.

3. A: Grapefruit contains furanocoumarins that inhibit intestinal CYP3A4, reducing intestinal metabolism and potentially increasing systemic drug exposure and toxicity.

   Examples listed in the lecture:

   ·        Statins: simvastatin, lovastatin, atorvastatin.

   ·        Calcium-channel blockers: felodipine, nifedipine and others.

   ·        Immunosuppressants: cyclosporine, tacrolimus.

   ·        Other examples include buspirone and certain benzodiazepines.

   Classic consequence: Increased simvastatin exposure → increased risk of muscle toxicity.

4. A: Calcium, iron, magnesium, and zinc can chelate certain medications, forming poorly absorbed complexes.

   ·        Tetracyclines: absorption may decrease with dairy products.

   ·        Fluoroquinolones: absorption may decrease with calcium, iron, magnesium, or zinc.

   ·        Levothyroxine: calcium and iron supplements can reduce absorption.

   Exam clue: A patient takes an antibiotic with milk or an iron supplement and the treatment becomes less effective → suspect reduced drug absorption.

5. A:

   ·        Vitamin K-rich vegetables: can reduce warfarin’s anticoagulant effect; maintain a consistent vitamin K intake rather than suddenly changing consumption.

   ·        St John’s wort: may reduce warfarin effectiveness by inducing CYP2C9.

   ·        Garlic, ginger, ginseng, ginkgo, and glucosamine: the lecture flags potential bleeding interactions; clinical risk varies by product and dose.

   ·        Alcohol: can affect anticoagulation and bleeding risk.

   ·        Aspirin and other NSAIDs: increase bleeding risk when combined with warfarin.

   Monitoring: INR (International Normalized Ratio).

6. A:

   ·        Tyramine is derived from the amino acid tyrosine and occurs in various foods.

   ·        Normally, monoamine oxidase (MAO) helps metabolize tyramine.

   ·        MAO inhibitors (MAOIs) reduce tyramine breakdown.

   ·        Excess tyramine can trigger a marked rise in blood pressure.

   Major danger: Hypertensive crisis.

   Exam association: MAOI + tyramine-rich food → potentially severe hypertension.

7. A:

   Medication	Nutrient affected / consequence
   Metformin	Vitamin B12 deficiency
   Proton pump inhibitors (PPIs)	Possible B12, magnesium, and iron deficiencies, particularly with prolonged use or in susceptible patients
   Loop diuretics	Potassium and magnesium depletion
   Thiazide diuretics	Potassium and magnesium depletion
   Corticosteroids	Increased bone loss; calcium/vitamin D metabolism affected
   Isoniazid	Vitamin B6 deficiency; peripheral neuropathy
   Orlistat	Reduced absorption of vitamins A, D, E, K
   Methotrexate	Folate depletion

   Exam trap: Long-term metformin use → consider vitamin B12 monitoring; orlistat → fat-soluble vitamins.

8. A:

   ·        Low albumin: can increase the free fraction of highly protein-bound drugs.

   ·        Warfarin: altered free drug levels may increase bleeding risk.

   ·        Phenytoin: low albumin changes free drug concentration, potentially causing toxicity even when total serum concentration appears misleading.

   ·        Obesity and older age: altered body composition and increased adipose tissue may prolong accumulation of some fat-soluble drugs.

   Clinical principle: Interpret drug levels and adjust treatment according to the individual patient’s clinical status, not albumin alone.

9. A: Important lecture examples:

   ·        Altered taste (dysgeusia): metronidazole, captopril, phenytoin, methotrexate/interferon.

   ·        Diarrhea: metformin, acarbose, tetracycline, metronidazole, colchicine, magnesium hydroxide.

   ·        Reduced appetite (anorexia): metronidazole, albuterol, amphetamines/methylphenidate, vinblastine.

   ·        Increased appetite: amitriptyline, chlordiazepoxide, prednisolone, testosterone; the lecture also lists several psychotropic and anticonvulsant drugs.

   ·        Glucose effects: insulin and acarbose lower glucose; corticosteroids and some diuretics can raise glucose.

   Exam clue: A medication may affect nutritional status not only through absorption but also by changing appetite, taste, GI function, or metabolism.

10. A:

    1.     Obtain a complete medication and dietary history, including OTC drugs, supplements, herbal products, alcohol, caffeine, grapefruit, and enteral nutrition.

    2.     Check whether each medication should be taken with or without food.

    3.     Counsel patients on relevant food restrictions and the importance of consistent dietary habits.

    4.     Monitor according to the medication and clinical circumstances:

    Medication / risk	Monitoring
    Warfarin	INR
    Antidiabetic treatment	Blood glucose
    Diuretics	Potassium and magnesium
    Levothyroxine	TSH
    Long-term metformin	Vitamin B12
    Relevant drug therapies	Renal and hepatic function as indicated

    High-risk groups: Older adults, pregnant women, growing children, patients with chronic disease or poor diets, people taking multiple medications, and those using alcohol or multiple supplements.

    Rapid-recall checklist

    Differentiate drug–nutrient vs nutrient–drug interactions

    Know absorption, metabolism, distribution, and excretion mechanisms

    Grapefruit → CYP3A4 inhibition → increased exposure to susceptible drugs

    Calcium/iron/magnesium/zinc → reduced absorption of certain antibiotics

    Warfarin: vitamin K consistency, interaction risks, and INR monitoring

    MAOI + tyramine → hypertensive crisis

    Memorize metformin–B12, isoniazid–B6, methotrexate–folate, orlistat–ADEK

    Low albumin can alter free concentrations of protein-bound drugs

    Recognize drug-induced changes in appetite, taste, diarrhea, and glucose

    Take a full diet, medication, alcohol, and supplement history

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SUMMARY

Lecture 1: Macronutrients & Chemistry

• Fuel Factors: Carbohydrates and protein yield $4\text{ kcal/g}$, fat yields $9\text{ kcal/g}$, and alcohol yields $7\text{ kcal/g}$.

• Fiber Categories: Differentiate between soluble fiber (delays gastric emptying, lowers cholesterol) and insoluble fiber (increases stool bulk, prevents constipation).

• Chemical Structures: Remember basic monosaccharides (glucose, fructose, galactose) and disaccharides (sucrose, lactose, maltose).

Lecture 2: DRIs, AMDRs & Dietary Guidelines

• AMDR Goals: Carbohydrates: 45%–65% (goal 60%); Fats: 20%–35% (goal 25%); Proteins: 10%–35% (goal 15%).

• Application: DRIs are designed for healthy populations, not acute/hospitalized patients.

• Exchange System: Grouping foods by macronutrient content rather than exact calories for easy meal planning.

Lecture 3: Nutritional Assessment & PEM

• ABCDE of Assessment: Anthropometric, Biochemical, Clinical, Dietary, Environmental/Economic.

• Kwashiorkor vs. Marasmus:

  • Kwashiorkor: Adequate energy intake with severe protein deficiency $\rightarrow$ edema, distended abdomen, preserved subcutaneous fat.

  • Marasmus: Severe deficiency of both protein and calories $\rightarrow$ severe wasting, emaciation, no edema.

• Visceral Protein Markers: Serum albumin and prealbumin reflect visceral protein status and systemic inflammation/stress.

Lecture 4: Life-Cycle Nutrition

• Pregnancy Weight Gain: Underweight requires 28–40 lbs; Normal weight requires 29–35 lbs.

• Caloric Increases: Third trimester requires an extra +450 kcal/day.

• Childhood Stunting vs. Wasting: Stunting = low height-for-age (chronic undernutrition); Wasting = low weight-for-height (acute undernutrition).

• Screening & Safety: MUST score $\ge 2$ indicates high risk requiring dietitian referral; Active untreated tuberculosis is an absolute contraindication to breastfeeding.

Lecture 5: Estimating Individual Energy & Nutrient Needs

• TEE Components: Basal Energy Expenditure (BEE) accounts for 60%–75% (most stable); Physical activity is 15%–30% (most variable); Thermic Effect of Food (TEF) is ~10%.

• Gold Standard: Indirect calorimetry measures $VO_2$ and $VCO_2$ to determine resting metabolic rate.

• Nitrogen Balance Formula: $\text{Intake} - \text{Output}$, where total output includes measured UUN plus a constant of +4 to account for unmeasured losses via sweat, stool, and wounds.

• Fluid Extremes: Infants/children (1–10 kg) require massive fluid volume ($100\text{–}150\text{ mL/kg}$), whereas older adults ($>65$ yrs) require significantly less ($25\text{ mL/kg}$).

Lecture 6: Enteral & Parenteral Nutrition Support

• The Golden Rule: If the gastrointestinal tract is functional, use it whenever possible.

• Parenteral Nutrition (PN) Indication: Used when the GI tract is non-functional, leaking, inaccessible, or nutrient needs cannot be met orally/enterally.

• Central vs. Peripheral PN: Central PN (CPN) is required for Total Parenteral Nutrition (TPN) because large central veins can handle high osmolarity and concentrated nutrient solutions.

• Refeeding Syndrome: Rapid feeding causes a sudden intracellular shift of glucose and nutrients, triggering a severe drop in extracellular phosphate, potassium, and magnesium, which can cause fatal cardiac arrhythmias.

Lecture 7: Food-Drug Interactions

• Chelation: Minerals like calcium, iron, magnesium, and zinc bind to drugs (like tetracycline antibiotics), forming insoluble complexes that block absorption.

• Grapefruit Juice: Furanocoumarins inhibit intestinal CYP3A4, decreasing drug metabolism and dangerously increasing systemic exposure/toxicity (e.g., statin-related muscle toxicity with simvastatin).

• Warfarin Interactions:

  • Dietary Vitamin K (spinach, kale) must remain consistent to maintain stable INR control.

  • St. John's wort induces CYP2C9, which diminishes warfarin's anticoagulant efficacy.

• MAOIs & Tyramine: Monoamine Oxidase Inhibitors block tyramine breakdown; consuming tyramine-rich foods (aged cheese, red wine, cured meats) triggers a severe, life-threatening hypertensive crisis.

• Key Drug-Induced Deficiencies:

  • Metformin $\rightarrow$ Vitamin B12

  • Isoniazid $\rightarrow$ Vitamin B6 (peripheral neuropathy)

  • Loop/Thiazide Diuretics $\rightarrow$ Potassium & Magnesium (hypokalemia/hypomagnesemia)