D224N2 Principles of Human Nutrition

Energy Requirements S Azam-Ali

Summary of the lecture

Revision BMR, activity Introduction to the other major components of energy expenditure

Major Components of Energy Expenditure

Basal Metabolic Rate (BMR) Activity

Postprandial thermogenesis Pregnancy & Lactation Growth Trauma, Sepsis & Burns

Basal Metabolic Rate

Basal Metabolic Rate

Usually the biggest single component of energy expenditure Energy expenditure of a subject lying at physical and mental rest in a comfortable warm environment, at least 12 hours after the last meal BMR normally measured in the morning before any physical activity and 12h after stimulants such as tea, coffee or cigarettes Heavy physical activity should be avoided the day before.

Energy Expenditure
Physical Activity Energy expended by use of skeletal muscle for any type of physical activity

Diet-Induced Thermogenesis Resting Metabolic Rate

Digestion, metabolism and storage of ingested macronutrients

Maintenance of basic physiological function

Energy Expenditure
Physical Activity Average daily energy expenditure (ADEE)
30-40 % Greatest source of variation Duration Type Intensity

Diet-Induced Thermogenesis Resting Metabolic Rate

10 %

Quantity and quality of macronutrients Body composition Gender Activity level

60-70 %

What affects BMR?

What affects BMR?

Body size accounts for half the variability in BMR in adult humans Body composition adipose tissue has a lower metabolic rate than lean tissue Age in adults BMR tends to decline with age as lean tissue is lost and adipose tissue is gained Sex Differences in body size and composition result in differences between the sexes.

Energy Expended in Activity

Activity is the work of the muscles Work can be measured (force x distance) Since work and heat are equivalent you can measure energy expended as heat produced above basal As heavier bodies require more energy to move than lighter ones this can be expressed as a multiple of BMR.

Physical Activity Ratios (PAR)

(energy cost of physical activity as a ratio of BMR)

PAR 1.2

Lying, sitting or standing at rest mopping floors, gardening, cleaning windows golf bricklaying

PAR 3.7

PAR 6.9

jogging, swimming, skiing.

Estimates of BMR in adult humans

Age range
10-17 18-29 30-59 60-74 75+

Male
0.074(wt)*+2.754 0.063(wt) + 2.896 0.048(wt) + 3.653

Female
0.056(wt) + 3.434 0.062(wt) + 2.036 0.034(wt) + 3.538

0.0499(wt) + 2.930 0.0386(wt) + 2.875 0.0350(wt) + 3.434 0.0410(wt) + 2.610

FAO/WHO/UNU 2004

Postprandial Thermogenesis
Metabolic rate remains increased up to 5h after a meal The size of the effect depends on the quantity of food eaten and its composition Overall it is normally assumed to be about 10% of the energy ingested Has been suggested that more energy is utilized in processing protein and carbohydrate than fat Postprandial thermogenesis is included in calculations of Physical Activity Ratios (PARs) so no need to make further adjustments

Estimated Average Requirements for Energy in Adults (MJ/d)

Age (y) 19-50 51-59 60-64 65-74 75+ Males 10.60 10.60 9.93 9.71 8.77 Females 8.10 8.00 7.99 7.96 7.61

Additional Energy Needs

Pregnancy
For a well-nourished women of between 60-65kg, producing an infant of 3.4kg, it has been estimated that they would gain approximately 12.5kg in body weight

Nutrition & Metabolism (Gibney, Macdonald & Roche) Chapter 6

Components of weight gain in pregnancy

(as described by Hytten & Leitch in 1960s) Products of Conception
Foetus Amniotic Fluid Placenta

4850g

Maternal Tissues
Fat Stores Extracellular Fluid Uterus & Breasts Blood

7650g

Total Weight gain

12500g

Components of weight gain in pregnancy

(as described by Hytten & Leitch in 1960s) Products of 4850g Conception
Foetus Amniotic Fluid Placenta 3400g 800g 650g

Maternal Tissues
Fat Stores Extracellular Fluid Uterus & Breasts Blood

7650g

Total Weight gain

12500g

Components of weight gain in pregnancy

(as described by Hytten & Leitch in 1960s) Products of Conception
Foetus Amniotic Fluid Placenta

4850g
3400g 800g 650g

Maternal Tissues
Fat Stores Extracellular Fluid Uterus & Breasts Blood

7650g
3345g 1680g 1375g 1250g

Total Weight gain

12500g

Energy requirements in Pregnancy

Average extra energy cost of such a pregnancy was estimated to be 350MJ over 9 months
Increased fat stores = 150MJ Foetus, placenta & other maternal tissues = 50MJ Energy requirements of new tissue = 150MJ

More recent studies

Since the 1980s several longitudinal studies of pregnancy have been performed These have included more careful measurements throughout pregnancy and more accurate determination of fat & lean tissue. These suggest early studies over-estimated maternal fat gain which may be more like 100MJ (rather than 150MJ)

Energy Cost of Pregnancy in Different Countries (MJ)

Component
Foetus Placenta Lean Maternal Tissues Maternal Fat BMR Total

Scotland
34.0 3.05 12.1 106 126 281

Gambia
29.9 2.34 10.4 27.6 7.9 78

Change in BMR during pregnancy in different countries

1.5

change in BMR (MJ/day)

1 0.5 0 0 -0.5 -1

scotland gambia

10

20

30

40

weeks

Energy Intakes During Pregnancy

Energy Cost of pregnancy is approximately 300MJ or 1.1MJ/day This is equal to about 10-15% above pre-pregnancy intake Can we detect equivalent increase in intake?

How is the increased energy requirement met?

Increase intake?

Most studies indicate only minor increases that account for no more than 25% of the extra requirement

Deceased activity?

Increased body weight might be expected to increase the energy cost of activity However, women might reduce pace or intensity of exercise? No evidence to suggest this is true

Further studies needed to explain how pregnant women balance energy requirements and intake

Energy Costs of Lactation

Major Determinants are volume and energy content of milk A well-nourished women will produce approx 750ml of milk/day for the first 4-6 months of full lactation Energy content of milk is 2.8kJ/ml so approx 2.09MJ/day are secreted The actual cost of synthesizing milk may add another 0.150-0.523MJ/day

Use of Stored Energy

A well nourished women may have stored an additional 2-2.5kg of adipose tissue Estimated that if this represents 147MJ and is mobilized steadily for 6 months then would offset energy cost of lactation by 0.84MJ/day This reduces full cost of lactation from 2.22.62MJ/day down to 1.36-1.78MJ/day If women does not breastfeed then she will not necessarily lose excess adipose tissue

Additional EAR for energy during lactation

Period Additional energy (MJ/day) +1.90 +2.20 +2.40 +2.00 +2.40 +1.00 +2.30

1 mth 2 mth 3 mth 4-6mth (group 1) 4-6 mth (group 2) >6 mth (group 1) >6 mth (group 2)

Group 1: progressively wean babies after 3 months Group 2: maintain milk as primary source of nourishment for 6mths or more

Energy & nutrient inadequacies in lactation

Lactating women are considered as high risk, particularly

Complete vegetarians & women who avoid dairy produce

Vitamin D, Calcium, Vitamin B12

Women who diet to lose weight

For women with adequate reserves milk energy output will be maintained even if they are losing 0.5kg/week.

Women on low income

Major Components of Energy Expenditure

Basal Metabolic Rate (BMR) Activity Post- Prandial thermogenesis Pregnancy & Lactation

Growth
Trauma, Sepsis & Burns

Basal Metabolic Rate Changes with Age

500 450 400 350 300 250 200 150 100 50 0 0 10 20 Age (y) 30 BMR(kJ/kg BW/day)

40

50

Contribution of different organs to BMR is different in infants & young animals

Reason for decrease in BMR as get older

As increase in age, muscle and adipose tissue increase in proportion of body weight Both these tissues have a low resting energy requirement Internal organs (Brain, Liver, Kidneys, Heart) have a high resting energy requirement In a young child (1-5y) these organs contribute approx 18% of body weight while in adult (2130y) this represents approx 6% Thus on a kg BW basis the child has a higher BMR

Growth
Infants and children have an increased requirement for energy to maintain growth Growth often considered to have 3 phases: infant, childhood and pubertal These phases not distinct but can merge into a continuum

Male & Female Growth

weight (50th percentile)
infant
80 70 60 50 40 30 20 10 0
age (y)

childhood

pubertal

weight (kg)

male female

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Male & Female Growth

height 50th percentile
infant
200 180 160 140 120 100 80 60 40 20 0

childhood

pubertal

height (cm)

male female

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 age (y)

Infant growth
Characterised by a rapid, but decelerating rate Foetal & new-born growth is primarily nutrientled and insulin regulated. This changes towards growth-hormone regulated over the the first 2-3 years In first 12-18 months growth velocity will vary considerably between individuals as they seek to attain their genetic potential Those growth-restrained in utero may show rapid (catch-up)_ growth while those over-nourished (e.g. maternal diabetes) may show slow growth

Infants and Young Children Very Vulnerable

Dependent on Carer High Growth Potential High demands but low stores Physiological immaturity reduces ability to respond to over- and under supply of nutrients In 1998 11.6 million under-fives died from malnutrition

Childhood Growth
Relatively slow and growth hormone led Will normally grow along a geneticallypredetermined centile (size relative to the age-specific population Deviation from the centile usually suggests illness, over- or under-nutrition This is why childrens growth is normally carefully monitored

Pubertal Growth
Changes occur in both physical size and body composition Growth velocity and nutrient requirements vary greatly because age of onset of puberty varies Delay may be due to illness or severe undernutrition

Estimated Average Requirements for Children (MJ/d)

Age 0-3mth 4-6mth 7-9mth 10-12mth 1-3y 4-6y 7-10y 11-14y 15-18y Males 2.28 2.89 3.44 3.85 5.15 7.16 8.24 9.27 11.51 Females 2.16 2.69 3.2 3.61 4.86 6.46 7.28 7.72 8.83

Major Components of Energy Expenditure

Basal Metabolic Rate (BMR) Activity Post- Prandial thermogenesis Pregnancy & Lactation Growth

Trauma, Sepsis & Burns

Energy requirements during injury, sepsis & burns

Clinical Nutrition (2005) Chapter19: Nutrition in Surgery & Trauma. Eds. Gibney, Elia, Ljungqvist & Dowsett

Injury increases the energy requirements due to the energy used for defence and repair In recent years it has been recognised that the extra-energy required has been over-estimated Burns elicit the most pronounced effect with increases in resting energy expenditure and loss of lean and fat body tissue If a burns victim loses more than 30% of their body weight they are likely to die

Energy Requirements in Sepsis & Trauma

Serious injury or illness can often be accompanied by starvation because the patient either cant or wont eat Starvation has evolved to allow the body to survive in periods when food is not available. Thus, energy use is minimized Injury & illness often requires the mobilization of energy and other nutrients for defence and repair This mechanism tends to take priority even in the presence of starvation

Comparison of Injury & Starvation

Starvation
Metabolic Rate Weight Nitrogen Hormones Decreased Slow loss, primarily from fat stores Losses reduced Early small increase in catecholamines, cortisol, GH then slow fall in glucagon & cortisol. Insulin decreased Initial loss

Injury
Increased Rapid loss. 80% fat, rest protein Losses increased Increases in catecholamines, glucagon, cortisol, GH Relative insulin deficiency Retention

Water & Na

Phases of Response to Injury

The Ebb Phase The Catabolic or Flow Phase The Anabolic Phase

The Ebb Phase

Lasts for a few hours Depression of metabolic function and a reduction in energy expenditure

Endocrine Response in the Ebb Phase

Increase in secretion of adrenaline & cortisol from the adrenal gland Increase in glucagon/decrease in insulin from the pancreas

Metabolic response in Ebb Phase

In response to hormonal changes

Glycogen breakdown in muscle for energy Glycogen breakdown in liver releasing glucose into blood Triacylglcerol breakdown in adipose tissue releasing free fatty acids into circulation

The Flow Phase

Hypermetabolic phase which may last for several weeks Magnitude of changes reflect the severity of the trauma

Physiological Features of the Flow Phase

Increased Heat Production Increased resting metabolic expenditure Increased respiration rate Increased pulse rate

All lead to an increased energy requirement

Effect of injury on resting energy expenditure

Injury
Uncomplicated surgery

Increase in requirement

Multiple fractures
Major surgery + sepsis

Major Burns

Effect of injury on resting energy expenditure

Injury
Uncomplicated surgery

Increase in requirement
+10%

Multiple fractures
Major surgery + sepsis

Major Burns

Effect of injury on resting energy expenditure

Injury
Uncomplicated surgery

Increase in requirement
+10%

Multiple fractures
Major surgery + sepsis

+10-20%

Major Burns

Effect of injury on resting energy expenditure

Injury
Uncomplicated surgery

Increase in requirement
+10%

Multiple fractures
Major surgery + sepsis

+10-20%
+25-50%

Major Burns

Effect of injury on resting energy expenditure

Injury
Uncomplicated surgery

Increase in requirement
+10%

Multiple fractures
Major surgery + sepsis

+10-20%
+25-50%

Major Burns

+50-100%

Energy Requirements of Adult Hospital Patients

Determine approx BMR Adjust for stress according to nomogram Add a combined factor for activity and Diet induced thermogenesis Bedbound immobile +10% Bedbound mobile + 15-20% Mobile on Ward + 25%

Glucose metabolism
Glucose required by damaged tissues as an energy supply during repair However, insulin resistance is common during the Flow Phase

Antagonistic effects of cortisol and growth hormone Increase plasma Free Fatty Acids.

Therefore, although plasma glucose is raised it is not necessarily available to tissues

Protein Metabolism
A recent study suggests that 16% of total body protein can be lost following severe trauma or sepsis over 21 days

Moderate trauma- protein synthesis Severe trauma- protein synthesis & protein degradation

Major site of loss is skeletal muscle Cardiac muscle largely spared Liver may actually increase synthesis of proteins associated with an inflammatory response (e.g. fibrinogen, C-reactive protein) while reducing others (e.g. albumin)

Protein Metabolism
Skeletal Muscle Protein
Essential AAs Branched chain AAs

alanine

glutamine

Liver & damaged tissues for protein synthesis

Protein Metabolism
Skeletal Muscle Protein
Essential AAs Branched chain AAs

alanine

glutamine

Liver & damaged tissues for protein synthesis

Liver for Gluconeogenesis

Protein Metabolism
Skeletal Muscle Protein
Essential AAs Branched chain AAs

alanine

glutamine

Liver & damaged tissues for protein synthesis

Liver for Gluconeogenesis

Damaged tissues Source of N for purine & pyrimidine synthesis for DNA/RNA

Fat Metabolism
Body fat becomes the major source of energy Increase in adipose tissue lipogenesis and plasma free fatty acids Not normally associated with an increase in ketogenesis (levels of insulin might be high enough to prevent this)

The anabolic phase

Catabolism declines and enter an anabolic phase Often associated with return of appetite Unless there are specific reasons, normal feeding should be resumed as soon as possible Nutritional therapy should aim to restore muscle mass and increase protein synthesis Recent evidence suggests that insulin treatment to reduce hyperglycaemia may reduce risk of infection

Consequences of over-feeding
In patients suffering from malnutrition it is important to avoid overfeeding, as it can have a number of complications

Too much protein can cause uraemia, dehydration and metabolic acidosis To much carbohydrate can cause hyperglycaemia and hypertriglyceridaemia To much fat can cause hypertriglyceridaemia and fat-overload syndrome