1. Basic concepts in nutrition
1.1.Energy Balance
The minimum amount of energy consumed by a person for chemical events in the body at rest is called basal metabolic rate (resting energy consumption, BET). It varies with height, weight, gender and age. The age-related decrease in basal metabolic rate is due to the decrease in muscle mass and the replacement of muscle mass by fat tissue, which has a slower metabolic rate. IET increases with increasing metabolic stress in the presence of excessive cytokine response due to infection and inflammation. The total energy (TET) consumed by the individual during the day is equal to the sum of IET and activity-related energy consumption (AET). While the activity factor for an active person in bed is 15-20%, it is 20-25% for an ambulatory person and 30-40% for an active person.
An amount of calories corresponding to the daily TET must be taken through oral foods. . In addition to daily energy needs, the intake of essential nutrients required for intracellular metabolic functioning is also important. Insufficient food intake will lead to weight loss (malnutrition), and intake of more calories than TET will lead to excessive weight gain (obesity). Malnutrition and obesity can coexist because consumption of any nutrient less than the required amount can lead to malnutrition. In recent years, the incidence of "obese malnutrition" in the elderly has been increasing. Especially in the elderly who were previously obese and had an acute illness, as food intake decreases, rapid muscle breakdown occurs due to the catabolic process, and sarcopenia develops over time. This condition is called sarcopenic obesity (Li and Heber, 2012). Pressure sores may develop in patients hospitalized for long periods of time. Moreover, being obese is a risk factor in this respect.
Foods are used in the construction and repair of tissues as well as in the maintenance of body functions. A complete diet should consist of enough carbohydrates and fats to meet daily energy needs, as well as proteins, vitamins, trace elements and water necessary for tissues and metabolism.
1.2.Carbohydrates
Carbohydrates are found in three forms in foods; starch, sugar and cellulose (fiber). The major sources of energy (calories) for humans are starch and sugar. Cellulose, gastrointesti It is not absorbed in the GI system. It adds volume to the GI content and ensures proper passage. Since tissues need continuous energy sources to continue their functions, carbohydrates should be consumed in appropriate amounts and stored for emergencies. The tissues where carbohydrates are stored are the liver and muscles. During emergencies, these resources are quickly consumed. After these sources are consumed, the body uses ketone bodies released as a result of the rapid breakdown of fats as an energy source. Flour, bread, potatoes and rice are often used as carbohydrate sources.
1.3.Proteins
Diet is the source of amino acids that play a role in many body functions and production/repair. taken proteins. 8 out of 20 amino acids cannot be synthesized in the body (essential amino acids) and they must be obtained with food. Proteins that do not contain essential amino acids have low biological value. Animal source proteins have high biological value. Foods containing proteins with the lowest biological value are grains.
As a result of insufficient intake of proteins, muscles, GIS, hematopoietic system, liver and many tissue functions are affected. While the daily protein requirement of an adult is 1 g/kg under standard conditions, it is 1.2 g/kg for the elderly (Houston et al., 2008). The need will be greater when losses increase. The difference between daily protein intake and loss gives an idea about whether there is protein malnutrition. Nitrogen balance measurements are used for this. The daily amount of nitrogen taken with food is calculated by dividing the daily amount of protein (grams/day) by 6.25. Losses from urine, feces and skin are nitrogen losses from the body. In special cases, losses may occur from different sources (burn, wound, fistula, etc.). Loss from urine can be understood by measuring urine BUN. Under normal conditions, the level of loss from feces and skin is 3-4 g/day. According to a meta-analysis, the daily nitrogen need of a normal healthy individual was found to be 105 mg/kg/day (Rand et al., 2003).
1.4.Lipids
Fats are the second most used energy source after carbohydrates. Its caloric value is nearly twice that of carbohydrates and proteins, and it provides the body with a large amount of stored energy. is the source. On the other hand, it is an important building block of cells. Linoleic, linolenic and arachidonic acid are essential fatty acids. Linoleic acids are found mostly in plants and less in animal fats. Linolenic acid is an omega-3 fatty acid and is mostly found in fish. Linoleic acid is used in the synthesis of arachidonic acid. Arachidonic acid is used in cell membrane synthesis and in the production of prostaglandin, prostocyclin and thromboxane.
1.5.Trace elements and vitamins
Minerals and vitamins contained in foods, alone They are elements that are not sources of energy but are of vital importance for various body functions. Significant metabolic and functional disorders occur in their deficiency.
Sodium (Na)is important in the maintenance of blood osmolarity and pressure (extracellular cation), potassium (K)is an important intracellular cation. . It has an important role in the heart and nervous conduction system.Calcium (Ca)andphosphorus (P)are important in bone and muscle metabolism.Magnesium (Mg)muscle It is important in metabolism, especially in respiratory muscles. Iron (Fe) and copper (Cu) are involved in many intracellular metabolic events. Fe is used in the production of Hgb (located in the Heme molecule). Cu is located in the cytochrome c complex, which is the respiratory enzyme complex. Daily oral Fe requirement is 10 mg for men and postmenopausal women, and 15 mg for premenopausal women.
Zinc (Zn)andselenium (Se)are included in the antioxidant system. . Metabolic needs increase in extremely stressful situations. Zn is also necessary for sexual functions and accelerates epithelialization in skin renewal (used in wound healing). Se is a situational necessity, especially in patients in ICU, and is required for immune system functions. An antioxidant element.
Antioxidant vitamins (A, C, E) have been shown to be effective in maintaining cognitive functions and protecting against Alzheimer's disease.
Vitamin Ain the epithelium. It plays a role in preventing the development of squamous metaplasia, wound healing and ensuring the continuity of photoreceptor pigment. It is found in fish oil, liver, eggs, butter and cream. Deficiency causes night blindness, dry eye syndrome, conjunctivitis Ada Bitot spots, dry skin and follicular hyperkeratosis are observed.
Vit B1(Thiamine) is involved in carbohydrate metabolism. In addition, it is found in central and peripheral nerve axons and takes part in nerve conduction activities. The main sources of thiamine are legumes, yeast, beef, cereals and nuts. As a result of its deficiency, heart enlargement, tachycardia and high-output heart failure, dry beriberi with peripheral edema and neuropathy, and wet beriberi with decreased peripheral reflexes and bilateral sensorimotor neuropathy are observed. Wernike encephalopathy due to chronic thiamine deficiency may be observed in alcoholics.
Vit B2 (riboflavin)deficiency causes corneal neovascularization, cheliosis, glossitis and inflammation in the oral mucosa.
Vit B3 (niacin) is the NAD, NAPDH coenzyme that takes part in the oxidation reduction reaction. In its deficiency, diarrhea, dermatitis and dementia (3D), which are the classical three-fold symptoms of pellagra, are observed.
Vit B 6 (Pyridoxine)deficiency causes cheliosis, stomatitis, glossitis, sideroblastic anemia, peripheral neuropathy, depression and confusion. .
Vit B6, B12 and folate are involved in homocysteine metabolism. Homocysteine is associated with coronary artery disease, stroke and cognitive impairment through endothelial dysfunction. Vit B12 deficiency is seen in 10-15% of the elderly and causes many neurological and hematological problems such as anemia, mood changes, cognitive dysfunction, ataxia and sensory problems in the extremities. It is associated with diseases.
Vit Ctakes part in the absorption of non-heme iron, carnitine biosynthesis, conversion of dopamine to norepinephrine, collagen metabolism and enzyme systems in drug metabolism. In its deficiency, petechiae, ecchymosis, perifollicular hemorrhage, gum bleeding, pericarditis, bleeding into the peritoneum and joints are observed.
Vit Dmuscle functions, cardiovascular system and bone health, immunity, cancer protection and metabolic signaling. It plays a role in many physiological events such as Recently, information on its relationship with mental health and cognitive functions in the elderly has been increasing. As a common decision, if the 25OH vitamin D level is below –25 nmol/L, there is insufficiency.
If it is below –50 nmol/L, The term deficiency is used.
While 800-1000 IU of vitamin D per day is sufficient for an adult patient, it is stated that the need for the elderly may be 1200-1500 IU and even up to 2200 IU per day for frail elderly.
Vit Kfactors 2, 7, 9 and 10 are involved in the production of protein C and protein S. Its deficiency may cause a tendency to bleeding due to related factor deficiencies. It has been found to be associated with the risk of hip fractures in older age.
1.6.Body composition
The ratio of body fat and other lean tissues to each other shows body composition. The main goal is to estimate or measure body fat and muscle mass most accurately. The most practical method to determine this is anthropometric measurements. These include weight, body mass index (BMI), extremity circumference measurements (arm or calf) and skin thickness measurements.
In recent years, more objective data about body composition can be obtained with some devices. One of these is bioelectrical impedance analysis (BIA). Bioelectrical impedance analysis is the measurement of the resistance of body tissues to a small amount of harmless electrical current. Electric currents pass more easily through body tissues where there is a lot of water (such as blood, urine, and muscles) than through other tissues (such as bone, fat, or air). With this method, the speed and power of electrical currents passing through the body are measured and these results are used to determine information such as height, weight, gender and the person's body fat ratio. Other methods include DEXA (dual energy X-ray absorptiometry), computed tomography (CT) and magnetic resonance imaging (MRI).
2.Evaluation of nutritional status
Detailed evaluation of nutritional status is not practically possible for everyone. For this reason, it is appropriate to identify risky individuals with short screening tests and then perform evaluation tests (Board of Directors and Clinical Practice Committee of ASPEN, 2010; Kondrup et al., 2003). In the evaluation of nutritional status, anamnesis information revealing the nutritional status of the person, system interrogation and physical examination findings including various anthropometric measurements are included.
2.1.Anamnesis
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