Nutrition and Metabolism Flashcards
how long is the small bowel in total
400-800 cm (12-20 feet)
less than ___ cm of small bowel without a colon requires TPN
< 100 cm
the length of the small bowel correlates to a person’s
height
a patient with 100-120 cm of remaining small bowel and an ileostomy may require
oral rehydration solution
A 72 year old patient with an end ileostomy is at risk for what deficiency
B12
B12 absorption requires
- normal GI function
- adequate HCL production
- adequate pepsin in gastric secretions
most of B12 is re absorbed via
the enterohepatic circulation via bile salts
patients with these conditions are at risk for decreased B12 absorption
- Pancreatic insufficiency
- impaired HCL production from H2 antagonist meds, PPI’s ,elderly & H Pylori
- decreased absorption from ileal resection, stomach resection and chronic malabsorption
patients who have decreased absorption resulting from ileal resection, stomach resection and chronic malabsorption are at risk for this vitamin
vitamin B12
vitamin K absorption primarily occurs in the
jejunum
thiamine (vitamin B1) is primarily absorbed in the
proximal small intestine, mainly the jejunum
vitamin A is primarily absorbed in the
upper small intestine/duodenum
this type of viscous fiber leads to gastric distention, which promotes a feeling of fullness, delays gastric emptying and PREVENTs absorption of nutrients in the small intestine
soluble fiber
_____ fiber PREVENTS absorption of nutrient in the small intestine
soluble
_____ fiber can improve blood glucose control from fiber induced gastric emptying
soluble fiber
accumulation of ___ is associated with Wilson’s Disease
copper
Copper accumulates in which organ
the liver
A genetic mutation of copper metabolism can lead to this disease
Wilson’s Disease
Copper relies on _____ for exceretion
normal biliary function
the acute phase of injury / infection suppresses the transport of
iron
in response to the acute phase of injury or infection you will have _____ serum iron and _____ serum ferritin
decreased serum iron (the body sequesters it to decrease the availability of iron for iron dependent microorganisms, decreased free radical production, and decreased oxidative damage to cell membranes & DNA),
increased transferrin to move the Fe around to sequester
the majority of dietary folate is reabsorbed via which mechanism
enterohepatic circulation
Dietary folate first converts to ____ by jejunal enzymes then enters into the intestinal cell. It is then further reduced and enters the _________ via ________
monoglutamate
portal circulation via, enterohepatic circulation
zinc deficiency, chronic ETOH intake, changes in jejunal pH and impaired bile secretion can limit ___ absorption
iron
oncotic pressure, passive diffusion, and plasma hydrostatic pressure govern the movement of ___ between plasma and interstitial spaces
fluid
choline supplementation has been tested as a treatment for what
hepatic steatosis
choline is needed for ____ transport and metabolism
lipid
low plasma choline in LTPN patients is associated with an increase in this level
Aminotransferases (liver enzymes)
Currently choline isn’t available for ______ admixes and has NOT been shown to improve ______
not available for IV PN
not shown to improve PNAC
the calculation of energy expenditure by analysis of gas exchanged via measurement of oxygen consumption and CO2 production is called
Indirect Calorimetry
Indirect calorimetry measures ____ consumption and ____ production
O2 consumption and CO2 production
what can decrease the accuracy of an indirect calorimetry study
- mechanical ventilation with FiO2 >60%, age >60, noisy busy environment, hot or cold room, currently getting routine care, and unstable nutrient intake for the previous 12 hours
Indirect Calorimetry calculates
resting energy expenditure (REE) and Respiratory Quotient
IC calculates resting energy expenditure using the abbreviated ____ equation
Weir
IC does not measure
total energy expenditure, nitrogen balance or heat released from a patient
an RQ of 0.5 indicates
mixed substrate, nutrition is appropriate
an RQ < 0.82 indicates
under feeding
lipid catabolism
you need to increase energy provision
an RQ >1 indicates
excessive CO2 production overfeeding lipogenesis increased respiratory demand you need to decrease total calories & decreased carbs
Simple carbohydrates with 1 CHO unit are called
monosaccharides
the 3 monosaccharides are
glucose, galactose, fructose
What is phosphofructokinase’s role in glycolysis
rate limiting enzyme
Phosphofructokinase is a rate limiting enzyme in glycolysis. Glycolysis is the process of breaking down ______ into _____. This occurs when the body is the ____ state when there is a high amount of _____ in the blood and the hormone ___ is elevated. This increases the level of ATP. PFK will then inhibit glycolysis to do what_________
- glucose to pyruvate
- fed state, high amount of blood glucose
- insulin
- start storing glucose as glycogen
when ATP is low during the starved state and glucagon is present in the blood, phosphofructokinase will be
activated
the majority of glycogen is stored in
the liver and skeletal muscle
glucose is stored in the liver and skeletal muscle as
glycogen
illness and trauma increases the production of counter-regulatory/stress hormones which include
epinephrine
glucagon
cortisol
growth hormone
stress hormones work against this hormone
insulin
during illness/trauma _____ production by the liver
glucose ( about 500 gram)
during illness and stress there is increased ___ breakdown, increased ______ oxidation to provide fuel for increased energy demand
protein
fatty
what are the options for selenium measurement
- plasma glutathione peroxidase
- whole blood plasma
- erythrocyte levels
if a patient has a decreased intake of chromium, what might happen to their serum blood glucose
increases (hyperglycemia)
what are the 2 actions of chromium
potentiates the action of insulin
plays role in protein, lipid & glucose metabolism
what are the signs/symptoms of vitamin D toxicity
soft tissue calcification, confusion, psychosis, tremor, hypercalcemia, hypercalciuria
when fat is present in the distal ileum, GI transit
DECREASES
when fat is present in the distal ileum, GI transit decreases which is known as the __________ which ____gastric emptying
ileal break
slows
indigestible plant material that forms in the stomach
phytobezoar
what are the treatment options for phytobezoars
cola, cellulose, surgical removal
is using papain enzyme recommending for breaking down phytobezoars
no, can be associated with PUD and breaks down normal tissues
How should psyllium fiber be delivered via a tube
- mix 1 TSP with 80mL of water
- inject via syringe
- then flush with 15mL/ water
GIVE SEPERATELY FROM OTHER MEDS
This RMR energy calculation takes into account body surface area and is effective at estimating nutrition needs in 55% of patients
Swinamer Equation
This predictive energy equation uses weight, height, age, sex, trauma and burns
Ireton Jones
This predictive energy equation uses weight height and age
Mifflin St. Jeor
What are the consequences of underfeeding in the critically ill
increased length of stay increased complications increased infections increased days on abx increased ventilator days
what are the consequences of overfeeding in the critically ill
hyperglycemia liver dysfunction fluid overload respiratory compromise increased CO2 production lipogenesis
when soluble fiber is added to liquid the liquid becomes more ______ there for _______ gastric emptying
viscous
delays gastric emptying
avoid _______ fiber in bezoar formation
soluble
soluble fiber is fermented in the ______, promotes ____ and ____ absorption and can help improve ___in tube fed patients
colon
sodium/water absorption
diarrhea
this type of fiber has a stool softening effect
insoluble fiber
insoluble fiber _______ transit time, results in more ______ bowel movements to help with ______
decreases (more rapid)
more bowel movements
aids in constipation
The FDA approved ILE that contains 4 oils , differing from 100% soybean oil ILE’s for fat emulsion contain
fish oil, olive oil, MCT oil
All FDA available injectable lipid emulsions contain _____ for emulsification, can be given ____ or _____ and provide essential _______
egg yolk phospholipids
centrally or peripherally
essential fatty acids
what is the 1/2 life of Albumin
14-20 days
1/2 life of retinol binding protein
12 hours
1/2 life pre albumin
2-3 days
1/2 life of transferrin
8-10 days
fat soluble vitamins require_______ for emulsification to be integrated into ____ and be absorbed into the _____
Bile Salts
micelles
enterocyte
A patient waiting for a lung transplant has been taking diuretics to control ascites and peripheral edema, what acid-base balance is expected?
Pt will lose potassium and chloride via urine via diuretics, bicarbonate will then increase in the body leading to metabolic alkalosis as the ECF water volume contracts
hydrogenated hydrophobic carbon atoms with a carboxyl group are known as
fatty acids
butyric acid is a
short chain fatty acid
what is the basic structure of a triglyceride
1 glycerol back bone with 3 fatty acids attached via an ester bond
_____ are derived from cholesterol & are produced by the liver. They help to emulsify triglycerides and form into micelles to hydrolyze for intestinal lipase and esterase to break down fat
bile acids
short chain fatty acids are made up of __ carbons
2
glycerol and fatty acids up to ____ carbons are able to be directly absorbed via the mucosal villi without bile acids
10 carbons
long chain fatty acids have greater than or equal to ____ carbons
14
long chain fatty acids require _____ for enzymatic digestion
bile salts
oxidation of fatty acids occurs in cells that
have mitochondria
cells that have mitochondria generate ATP via _________ which provides the majority of cellular energy
oxidative phosphorlyation
fatty acids are transported into the ________ ______ then go through _____ where energy is released as ATP
mitochondrial membrane
beta oxidation
fatty acids provide much more _____ than carbohydrates
energy
fat is stored in
adipocytes
linoleic and alpha linolenic acid are known as essential fatty acids becuase
they cannot be synthesized by humans and must be obtained by the diet
linoleic and alpha linolenic acids are both long chain fatty acids and require _____ to enter into the mitochoondria
carnitine
a 50 year old male weighs 80 kg, what volume is his intravascular space
- a 50yoM is about 60% TBW: 0.6 x 80 kg = 48 liters
- the intravascular space is in the extracellular fluid
- extracellular fluid makes up 1/3 of TBW, so 48 x 0.333 = 16liters.
- of the extracellular fluid, the intravascular fluid makes up 25% of that fluid so the answer is 4Liters
the more fat a person has the _____ total body water they have
less
the more muscle a person has, the ____ total body water they have
more
Sorbitol induced hypokalemia is likely secondary to
increased potassium losses from stool
what range is considered mild hypercalcemia
10.3-11.9
the first line of treatment for mild hypercalcemia (10.3-11.9) is
hydration and ambulation
severe hypercalcemia is considered a serum value of
> /= 14 mg/dL
when a patient is severely hypercalcemia (>14 mg/dL) what is the treatment option
Saline hydration to correct volume depletion
Lasix to enhance renal calcium excretion
ambulation
Hemodialysis if there is renal insufficiency
If 2/2 malignancy: bisphosphonates (but has delayed onset)
absorption of large polypeptides, oligopeptides, and free amino acids occurs in this part of the GI system
small intestine
There is ____ protein digestion in the mouth. ____ is secreted by the stomach of parietal cells in the stomach to denature proteins and coverts inactive ________ to active ________ which hydrolyzes peptide bonds. Peptides then is mixed with chyme when it enters into the _____ where the majority of protein digestion occurs.
minimal hydrochloric acid pepsinogen pepsin duodenum
Nitrogen balance measures 24 hour
urine urea nitrogen
urea makes up ______% of total urinary nitrogen losses
80%
urea/nitrogen losses are affected by ____ during hospitalization
stress
this semi essential amino acid has a role in wound healing and immune function. Don’t supplement in the critically ill as its use is controversial
arginine
this is a tri-methyl amino acid which is a cofactor for the transition of acetyl-carnitine to transport fatty acids into the mitochondria
carnitine
The transformation of free long chain fatty acids to acetylcarnitine requires
carnitine
in what part of the body are essential amino acids oxidized
the liver
the liver has a key role in ____ metabolism/oxidation which accounts for 57% of amino acids
protein metabolism
Which of the following is a common effect of enteral fiber on the intestinal tract
improves diarrhea
what are possible complications of fiber containing enteral formulas
flatulence, bloating, abdominal pain
Insoluble dietary fiber may help to regulate normal defecation by
increasing fecal weight/bulk
Insoluble fiber is not _______ by the colon. This creates a ___ which holds water and ____ the stool to ease evacuation
degraded/broken down
gel
soften
consumption of soluble fiber MAINLY contributes to
lower total cholesterol and lower low density lipoprotein cholesterol without changing HDL
during extended periods of fasting (starvation) the main source of energy is
fatty acid oxidation
during starvation, glucose utilization is substantially ____ as well as the hormone ___. _____ then is more concentrated promoting fatty acid oxidation
decreased
insulin
glucagon
glycogen stores can sustain normal activities in a healthy 70kg man for approximately
1 day
100g (liver, ~390 kcal)
300-400g (~1500 kcal)
glucose and galactose gain access to enterocytes via
sodium glucose transporter 1
which water soluble vitamins don’t require sodium co-transporters for absorption
B12 (needs intrinsic factor)
Folic Acid
Loss of parietal cells after a gastrectomy may lead to a deficiency of
Vitamin B12
Loss of parietal cells of the stomach which binds to ________ is taken up by receptors in the distal ______
vitamin B12 (cyanocobalamin) distal ileum
Loss of parietal cells, therefor decreased B12 absorption can occur from
gastrectomy, pernicious anemia, chronic gastritis, loss of terminal ileum
what facilitates the absorption of sodium in the lumen of the small intestine
glucose
oral rehydration fluid used to treat diarrhea should contain _____ and ______ to enhance sodium and water transportation
NaCl and Glucose
medium chain triglycerides don’t require formation of micelles or bile salts for absorption because they are
water soluble and go directly into portal circulation
muscle atrophy that accompanies bowel rest may result from an absence of
glutamine
_____ is the main metabolic fuel for intestinal cells
glutamine
An enzyme deficiency commonly seen in Asia, Mediterranean, African American and Native Americans is
lactase
symptoms of diarrhea, bloating and flatulence after the ingestion of sugar are caused by a deficiency of______. This causes a a shift of water into the intestinal lumen. As colonic bacteria act on remaining _____ this increases osmolarity/diarrhea as well as increased are formed which causes flatulence and bloating
brush border oligosacchardiases
oligosacchardies
(undigested parts of carbohydrates: CHO - polysaccharide-oligosaccharide-disaccharide- monosaccharide
The majority of fat digestion occurs in the _______ by the enzyme ______. A smaller amount of fat digestion occurs in the ____ by _____ and the _____ by _______
Duodenum
Pancreatic lipase
Mouth/Lingual Lipase
Stomach/Gastric Lipase
what are the 3 pancreatic enzymes that digest fat in the duodenum/smallintestine
pancreatic lipase (triglycerides)
cholesterolesterhydrolase (cholesterol)
phospholipase (phospholipids/fat sol vits)
Bile acid’s role in fat digestion is to
emulsify
A 35 year old patient with a recent history of binge alcohol drinking over the holidays comes in complaining about abdominal pain which radiates to the back. Pt has a history of pancreatitis. The pt reports nausea and a decrease in oral intake for over 1 week, abdominal bloating and oily stools. This patient may benefit from (PN, evaluation for pancreatic exocrine insufficiency, maintain NPO status until symptoms improve, or vitamin supplementation)?
He should be evaluated for pancreatic insufficiency as may have fat malabsorption causing his symptoms
symptoms of pancreatic exocrine insufficiency are
diarrhea, abdominal pain/distention, bloating, cramps, flatulence, weight loss oily stools
what is the recommended therapy for pancreatic exocrine insufficiency
PERT enzyme therapy
what is an amino acid that is conditionally essential and a primary fuel source for enterocytes
glutamine
what is the most abundant amino acid in the body
glutamine
in what situations does the body have an increased demand for glutamine
sepsis, trauma, exercise
decreased _____ levels are associated with mucosal atrophy, impaired immune function and decreased protein syntesis
glutamine
a patient is getting 95 grams of protein , how much nitrogen is this
(16% or /6.25) = 15 grams of Nitrogen
A critically ill trauma patient who is 70kg and has a BMI of 23 should get this much protein
105 to 144 grams (1.5-2 g/kg)
patients on CRRT or a BMI > 30 should get how much protein
2-2.5 g/kg/day
what protein transports oxygen from the lung to the rest of the body
hemoglobin
which transport protein contains iron
hemoglobin
_______ transports lipids, vitamins, minerals, albumin and hemoglobin
proteins
what 3 organs have the necessary enzymes for gluconeogenesis
liver, kidney, small intestines
what is the PRIMARY organ responsible for gluconeogenesis
liver
the range of intake for a particular energy source that is associated with a REDUCED risk of a chronic disease. Includes omega 3/ omega 6 fatty acids and total fat
AMDR: acceptable macronutrient distribution range
the highest level of intake that is likely to pose NO risk of adverse health effects to almost all individuals in a general population is known as the
TUL: Tolerable Upper Limit
The average daily nutrient intake level that is estimated to meet 1/2 of the needs of healthy individuals in a particular life stage/gender group is called
EAR: estimated average requirement
what type of oils are included in commercial enteral formulas to provide a good source of linoleic and alpha linolenic acid
soybean, corn, safflower, canola
which oils are rich in linoleic acid
soybean, safflower, corn
which oils are rich in alpha linolenic acid
canola, soybean oil
The most predominant clinical change seen with essential fatty acid deficiency is
a dry scale rash
the energy for glucose transport is provided by the active transport of what
sodium OUT of the cell
____ and sodium are co-transporters. High concentrations of sodium in ____ during digestion increases glucose transport into the cell. Sodium moves into mucosal cells along a concentration gradient and brings glucose along. The active transport of SODIUM _____ of the cell provides the energy for glucose transport. The transport of sodium ___ of the cell maintains a concentration gradient needed for Na to shuttle more glucose into mucosal cells.
Glucose and Sodium
Chyme
Out of the cell
Out of the cell
A 32 year old female presents with a sunburn like rash. She has been following a low carb, vegetarian diet. She notes recent weight loss, diarrhea and low energy as well as drinking alcohol daily. What deficiency does she most likely have
Niacin deficiency with the sunburn like rash and low intake of carbs which are fortified with niacin and meat as she is a vegetarian
what are the primary food sources of niacin
meat, fish, poultry, fortified breads and cereals
what are the primary risk factors associated with niacin deficiency
malabsorptive disorders vegetarian / low carb diets individuals with alcoholism older adults patients on antitubercular meds such as isoniazid or mercaptopurine
The medication Ursodiol facilitates the absorption of
fat
___ is essential for the digestion of fat
bile
bile is made up of these components
bile salts bile pigments cholesterol lecithin electrolytes alk phos
The metabolites that make up bile are (electrolytes)
sodium and potassium
____ are metabolites of cholesterol which form micelles. They have hydrophilic portions that face out and hydrophobic portions that face toward the enter, where lipids collect. lipids are then transported to the brush border of the intestine and are absorbed
bile salts
a 72 year old female with impaired renal function was recently prescribed sulfamethoxazole and trimethoprim for a UTI. What electrolyte disorder is most likely to occur
hyperkalemia
which medications can cause hyperkalemia
sulfamethoxazole, trimethoprim, aldactone
what are some causes of hyperkalemia
too much IV provision
too much intake
IMPAIRED RENAL FUNCTION/ Renal INSUFFICIENCY
the first line of therapy of hyperkalemia is
calcium gluconate (1-2 mgIV over 10 mins)
when should a patient with hyperkalemia be treated with IV calcium gluconate
when symptomatic with ECG changes the restore membrane excitability
calcium acts as a ____ to cardiac conduction abnormalities seen in severe hyperkalemia
antagonist
a patient has had an NG tube to suction for the past 48 ours secondary to a post op ileus. What electrolytes will be lost?
potassium, sodium or chloride
a patient in the ICU has acute, severe diarrhea. Which acid base disorder will most likely be present
metabolic acidosis from the loss of bicarb in the stool (normal anion gap)
metastatic calcification is a complication of _______
hyperphosphatemia
the most serious complications of hyperphosphatemia are
metastatic/vascular calcification of non skeletal tissues when calcium and phos exceed 55 mg2/dL 2
