Energetic balance, nutrition, physiology and pathological physiology

Energetic balance,nutrition,physiology and pathological physiology „block seminar“ Eva Miarkova, Petr Marsalek warning: the PDF version of this presentation is not an official study material First Medical Faculty, Institute of Pathological Physiology of 33

pathological physiology of nutrition - disorders of absorption, digestion and metabolism - disordersby inadequate (composition of) nutrients - disorders by imbalanced energy input and output (obesity, malnutrition)

positive/ negative energetic balance • norm - equal energy balance • energy input (in the time range of several days) higher then basal/ actual metabolic demands – weight gain, overeating, positive energetic balance • energy input (in the time range of several days) lower then basal/ actual metabolic demands – weight loss, malnutrition, negative energetic balance of 33

positive energetic balanceanabolism • positive energetic balance (fats, sugars, proteins, alcohol) • insufficient energy output (lack of physical activity) • amount of nutrients approaching toxic doses (see … toxicity of fat soluble vitamins, A, D, K, elements: Se, Na (?), …) pathology: immobilization, hypo-thyreosis, Cushing syndrome (=hyper-cortisolism), etcetera. of 33

negative energetic balance,catabolism • insufficient input of energy and/ or some of nutrients • condition of most acute diseases • metabolic disorders (malabsorbtion, maldigestion) • metabolic control disorders, thyroid gland disorders • Malnutrition: … • vitamins (eg. thiamine, riboflavin, B, C, fat soluble: A,D) • minerals (Ca, Fe, I, Se, F) • essential fatty acids (linoleic acid) • esential amino acids (lysine, methionine, tryptofan) • and so on…

positive energetic balance „Physiological weight gains“ • Young age - growth • Women – pregnancy, breast-feeding • Women – hormonal changes (menopause, age of 50) • Men – similar age group (age of 40 – 50) of 33

obesity Causes of obesity: • Genetic factors • High level/ voluntary feeding behaviors • CNS feeding behaviors control disorders • Temperature control disorders • Hormonaldisorders (hypothyreosis) • Hyper-fagia/ (mental) bulimia • Addictive substance abuse • Gravidity with associated disorders • (Classical) stress, long term stress of 33

types of obesity • „male type obesity“ (android) - belly/ visceral fat (type „apple“, „beer belly“, etc.) - (relative) insulin resistency and metabolic(Reaven) syndrome - higherrisk of metabolic andcardio-vascular disorders • „female type obesity“ (gynoid) - fat thighs/ rear parts (type „pear“) > „mixed type obesity“ , abdominal, example: Cushing syndrome of 33

alternativeclassifications of obesity types Primary, secondary, pathologic, etc ... Hyper-plastictype of obesity • higher number of adipocytes • early age and puberty • low reactivity to dietary measures Hyper-trofic typeof obesity • enlargement of adipocytes • after the termination of growth period (age over 20) • lower insulin and katechol-amin reactivity • better reactivity to reduction diet of 33

evaluation of obesity • according Broca and others: body height in cm - 100 >=<body mass in kg • BMI (body mass index) BMI = body mass (kg)/square of height (in m) > waist length > but: paradoxicalweight gain in edemas, ascites, etc. of 33

BMI (body mass index) values • under 18.5 - low weight • 18.5 – 24.5 – normal weight • 25 – 29.9 – over-weight • 30 – 34.9 - obesity • 35 – 39.9 – extreme obesity • 40 and more - clinical (pathological) obesity of 33

evaluation of obesity Parameters: • waist circumference • waist/ hip ratio (android vs. gynoid, > 0.85 female, > 1.0male) • front-back body diameter (SAD sagittal abdominal diameter) • Skin fold thickness: above triceps, under blades, on the belly, measured by caliper …some other parameters related tocardio-vascular obesity complications, comparable to BMI. of 33

epidemiology of obesity • Czech Republic – alarming rate alarming obesity in children • pathologic obesity • According to the type – abdominal obesity – highest cardio-vascular risk of 33

obesity -vegetative center: hypotalamus, -voluntary control: cerebral cortex of 33

weight reduction diets • Short term – short term effect – the goal might be to introduce new feeding behavior, not efficient, weight fluctuation • Long term – less drastic, more efficient of 33

reduction diet sugestions 1. Water ad libitum – hydration is important 2. Lower energy input – down to 30% 3. Controllable amount of nutrients 4. Taste acceptability, variability 5. Not causing hunger and fatigue (glycemic index ?) 6. Affordable, preparation not time consuming 7. Introducing/ changing dietary habits 8. Goal setting – motivation - 1 9. Health improvement – motivation - 2 10. Should not be in contradiction with other dietary measures of 33

wrong weight reduction diets • mental aspects – aversive reaction to food (bulimia, anorexia), too fastbody weight reduction can cause health problems • physiological aspects –insufficient supply of vitamins and minerals – fatigue, anemia, higher susceptibility to infections, women – hormonal problems Long term dangers – associated with growth, pregnancy, breast feeding, metabolic disorders of 33

malnutrition • insufficient input of energy and/ or some of nutrients • pathological effects – changes in nutritional demands • old age, catabolic states • wrongly applied reduction diets • diseases in general of 33

malnutrition • malnutrition manifests in shortage of following nutrient factors: • vitamins (eg. thiamine, riboflavin, B, C, fat soluble: A) • minerals (Ca, Fe, I, Se, F) • essentialfatty acids, amino acids (linoleic acid, lysine, methionine, tryptofan) • proteins • energy of 33

malnutrition in developing countries • nutritional energy shortage together with lack of proteins and vitamins, especially the B group • malnutrition in children: KWASHIORKOR • low hygiene, worse access to information, shortage of basic foods • bacterial and other microbial contamination of food • further nutrient loses by non-adequate food preparation of 33

Kwashiorkor – large bellies – ascites caused by lower plasmatic protein concentration-> low oncotic pressure ->see Starlinghypothesis of 33

(mental) bulimia • eating disorder – mental/ psychiatric disorder • overeating with compulsive and repetitive induction of vomiting • alternating periods of compulsive fasting and overeating, compulsive vomiting, laxative abuse, with dehydration as a complication • mostly in teenager women, but higher age women and men are not exceptions of 33

Bulimia consequences/ complications: • teeth decay and esophagal mucosa erosions - due to vomiting • alkalosis and sodium depletion - due to vomiting • gastric mucosa changes • cardiovascular complications – Na, K, Cl imbalances • psychiatric problems, depressions = real cause of the disease of 33

Bulimia -dominating cause is psychiatric disorder -besides organ changes shown here this leads to pathologic obesity and - body weight fluctuations of 33

Pathogenesis: - “simple” way to elicit the vomiting reflex - food abundance in developed society -fixation of pathologic dietary habits of 33

(mental) anorexia • eating disorder – mental/ psychiatric disorder • mostly women – estimates up to 3 % of population • fasting together with high physical activity – negative energy balance • imprinting of “ideal beauty” pattern - consequences/ complications: • hormonal imbalance – loss of menstruation, infertility • muscle atrophy, internal organ protein and weight loss • skin problems, hair and nails loss etc. of 33

mental anorexia • Associated psychiatric conditions: depressions, neurotic disorders, auto-mutilation, hysterical disorders • internal organ protein and weight loss leads to secondary malabsorbtion – vicious circle, parenteral nutrition indicated • body weight under 30 kg – life threatening condition • differential diagnosis – true anorexia = kachexia, esophagus and swallowing disorders, GIT tumors, etc. of 33

anorexia -dominating cause is psychiatric disorder -organ changes are similar to “true” malnutrition and starvation of 33

therapeutic approach to anorexia • difficult, psychiatry, in-patient section • prevention – education, psychological view – respect to self is needed, unfortunately this is domain of psychiatry • food variety intake regimes • introduction of new feeding habits • dangerous, epidemiologically important due to contemporary TV and other media of 33

(Czech) standard diets in hospital 0. liquid diet 1. puree, gruel d. 2. non-iritating (GIT favoring) d. 3. balanced d. 4. reduced fats d. 5. fiber free d. 6. low protein content d. 7. low cholesterol d. 8. weight reducing d. 9. diabetic d. 10. low sodium d. 11. re-alimentation d. 12. toddler d. 13. childrens’ d. 0. tekutá 1. kašovitá 2. šetřící 3. racionální 4. s omezením tuků 5. bílk., bezezbytková 6. nízkobílkovinná 7. nízkocholesterolová 8. redukční 9. diabetická 10. neslaná šetřící 11. dieta výživná 12. strava batolat 13. strava větších dětí of 33

Other specialties Gluten free diet - Coeliac (celiac) disease, celiac sprue Pancreatic diet - Subsequent procedure from liquid to puree/ gruel diet, and gradual re-alimentation, dyspeptic syndrome, chronic pancreatitis Chronic renal failure diet – low/ defined protein content diet -more strict in patients not participating in dialysis program of 33

Other specialties Lactose intolerance diet • In suspicion of lactase deficiency Occult GIT bleeding diagnostic diet - 3 days before GIT functional investigation Schmidt’s diagnostic diet - 3 days before GIT functional investigation of 33

parenteral nutrition • By-passing GIT • Intra-venous/ v. subclavia, balanced: sugars, fat emulsions, amino-acids, vitamins, minerals • Complete parenteral nutrition: energy requirements, water load, osmolarity, utilisation • GIT surgery, Crohn’s disease, postoperative care after acute abdomen of 33

Energetic balance, nutrition, physiology and pathological physiology