Chapter 16

Nutrition and Drugs

for Metabolism

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Chapter 16
Topics

Physiology of Nutrition
Micronutrient Abnormalities
Enteral and Parenteral Nutrition
Obesity
Herbal and Alternative Therapies

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Physiology of Nutrition
Evaluating Nutrition Status
Both external and internal physiological
processes are involved in weight maintenance
To evaluate nutrition status, compare normal
body weight for a patients age and
development with ABW
Someone within the normal range
Shows no signs of vitamin or nutrient
deficiency
Maintains an appropriate body weight
and makeup
Best indicator of nutrition status in children is
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appropriate growth (including height and

Physiology of Nutrition
IBW (Adults)
IBW is the weight for a given height that is
associated with maximum longevity and health
To assess basic nutritional status, compare
patients ABW with IBW
Many times, IBW is used to determine proper
weight-based dose (sometimes ABW can be
used)
To Calculate IBW in Adults
Males: IBW (kg) = 50 + (2.3 height in inches
over 5 feet)
Females: IBW (kg) = 45.5 + (2.3 height in
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5
inches over 5 feet)

Physiology of Nutrition
BMI
Another way to assess appropriate weight for
height
Used to identify both undernutrition and
overnutrition
Due to increased muscle mass, some males
and athletes may not be considered
overweight until BMI reaches 27
To Calculate
In children
and teens, BMI
BMI must be compared
to averages
inweight
growth(kg)
for age
to be interpreted
BMI =
/ [height
correctly
(m)]2
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Physiology of Nutrition
Calories
Good nutritional status is maintained through
appropriate energy intake and expenditure
Energy intake is measured in calories (kcal/kg)
Appropriate daily caloric needs depend on age
For adults, an intake of 25 kcal/kg of body
weight a day is usually adequate to maintain
basal metabolic rate
Malnourished and critically ill patients need
more calories
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Physiology of Nutrition
Nutrients
In addition to calories, the body needs
appropriate amounts of protein, carbohydrates,
fluids, micronutrients
Protein needs vary depending on age, disease
state, and clinical condition
Micronutrients include vitamins and minerals
(electrolytes and trace elements); key role in
many metabolic processes
In 2005, federal government published RDIs for
vitamins and essential trace elements
RDI values of micronutrients measured in
8
mg, mcg, IU Paradigm Publishing, Inc.

Physiology of Nutrition
Obesity and Malnutrition
Obesity is overnutrition; an obese body
composition has significantly more fat than is
considered normal or healthy
Malnutrition is a lack of adequate nutrient
intake to supply basic metabolic needs; related
to two conditions
Overall lack of calorie or protein
consumption
Specific micronutrient (vitamins, minerals)
deficiency
Malnutrition is most prevalent in
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underdeveloped
countries and in children.

Physiology of Nutrition
Malnutrition Conditions
Marasmus is a chronic condition caused by
inadequate caloric and protein intake over a
prolonged time
Cachexia is the wasting away of muscle and fat
tissue due to starvation and the effects of
cancer
Kwashiorkor is a condition in which caloric
intake is adequate, but protein intake is
deficient
Patients appear well nourished, but fluid
accumulates in the abdomen and feet
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Micronutrient Abnormalities
About Micronutrients
Deficiencies or excesses of vitamins, minerals,
and essential fatty acids can cause significant
morbidity
Fat-soluble vitamins (A, D, E, and K)
accumulate in fatty tissue and can build up in
the body over time
Water-soluble vitamins (eight B vitamins and
vitamin C) are easily excreted in urine;
overdose is uncommon
Vitamin and mineral deficiencies measured
with lab tests
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Vitamins and minerals
are dietary supplements11

Micronutrient Abnormalities
Vitamin A
Part of a family of compounds called retinoids
Necessary for vision, growth, bone formation,
reproduction, immune system function, and
skin health
Sources: eggs, whole milk, butter, meat, and
fish
One compound, beta carotene, can be found
in vegetables (especially carrots) and fruits
Indications: cases of deficiency; cataracts;
reducing complications of HIV, measles, and
malaria
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Micronutrient Abnormalities
Thiamin (B1)
Important coenzyme involved in carbohydrate
metabolism
Sources: pork, cereal, grains, peas, beans, and
yeast
Indications: cases of deficiency, which are most
common during pregnancy and during alcohol
withdrawal

Riboflavin (B2)
Coenzyme in tissue respiration and normal cell
metabolism
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13
Sources: milk, cereal,
green

Micronutrient Abnormalities
Niacin (B3) or Nicotinic Acid
Essential vitamin B complex for body reactions
that produce adenosine triphosphate (molecule
in cellular energy production)
Necessary for the regulation of cholesterol
production and activity
Sources: yeast, lean meats, peanuts, peas,
beans, whole grains, and potatoes
Indications: cases of deficiency, lowering of
cholesterol (lowers triglycerides and LDL and
raises HDL)
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Micronutrient Abnormalities
Pantothenic Acid (B5)
Precursor of coenzyme A
Necessary for the proper metabolism of
carbohydrates, proteins, and lipids
Sources: vegetables, yeast, cereal, organ
meats (liver, kidney, heart)
Indications: cases of deficiency

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Micronutrient Abnormalities
Pyridoxine (B6)
B vitamin that the body converts to the
coenzymes responsible for amino acid
metabolism
Sources: most foods of plant or animal origin
Indications: cases of deficiency; types of
anemia and seizure disorders; alcoholic
patients with nerve damage; patients with TB
who take isoniazid, which depletes B6

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Micronutrient Abnormalities
Biotin (B7)
Coenzyme involved in metabolism
Deficiencies of it are associated with altered
absorption, such as short gut syndrome
Sources: green leafy vegetables, liver, carrots,
almonds
Indications: cases of deficiency

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Micronutrient Abnormalities
Folate (B9) or Folic Acid
Essential for intracellular metabolism and the
breakdown of homocysteine (amino acid
associated with CV disease); involved in
serotonin (a neurotransmitter) production
Deficiencies cause anemia and neural tube
defects in a developing fetus; deleterious
effects on the cardiovascular system
Sources: green leafy vegetables, red meat;
food additive
Indications: cases of deficiency, pregnant
women or those planning to get pregnant, end Paradigm Publishing, Inc.
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stage kidney disease,
depression, chronic

Micronutrient Abnormalities
Cyanocobalamin (B12)
Coenzyme necessary for cell reproduction,
normal growth, and red blood cell production
Necessary for proper use of folate in the body;
deficiency causes pernicious anemia
Sources: meats, fish, milk, bread
Indications: cases of deficiency (common in
elderly, strict vegetarians); pernicious anemia;
end-stage renal disease

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Micronutrient Abnormalities
Vitamin C (Ascorbic Acid)
Important in immune system function and as
an antioxidant (reduce DNA mutations that
lead to cancer)
Sources: vegetables and fruits, especially citrus
fruits
Indications: cases of deficiency (scurvy),
improvement of iron absorption
Indications (other): protein metabolism in
premature infants, macular degeneration,
seasonal allergies, prevention of the common
cold
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Micronutrient Abnormalities
Vitamin D
It maintains calcium and phosphate levels in
the blood; enhances intestinal absorption of
calcium (bone health)
Possible role in cardiovascular health,
development of cancer, and respiratory
disease
Two active forms: ergocalciferol and
cholecalciferol
Ergocalciferol is in plants and yeasts;
cholecalciferol is made in the skin in
response to sunlight
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Sources: fortified milk, some eggs, tuna,

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Micronutrient Abnormalities
Vitamin E (Alpha Tocopherol)
Fat-soluble vitamin
Sources: vegetable oils, cereals, grains, animal
fat, meat, poultry, eggs, fruits, and vegetables
Indications (topical): improvement of skin
health
Indications (supported by studies): macular
degeneration, Alzheimers disease, reduction
of risk for some types of cancer and dementia
Indications (controversial): improvement of
immune system function, diabetic retinopathy,
cardiovascular disease
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Micronutrient Abnormalities
Vitamin K or phytonadione
Coenzyme for hepatic production of blood
clotting factors
Sources: green leafy vegetables, broccoli,
brussels sprouts, plant oils, margarine
Deficiency can be caused by drug therapy
Indication: cases of deficiency, enhanced blood
clotting, reversal of the effects of warfarin (an
anticoagulant)

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Micronutrient Abnormalities
Vitamins: Side Effects and Cautions
Side Effects: most result from excess intake
and mimic conditions of vitamin toxicity (see
Table 16.4)
Side Effects (niacin products, common):
flushing, hot flashes, a sensation of prickly skin
Cautions: doses higher than the RDI of vitamin
A are category X (contraindicated) in pregnant
women
Vitamin A in excess of 800 mcg a day has
been associated with birth defects
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Your Turn
Question 1: A patient who is undergoing
chemotherapy and radiation says food does not
taste good, and he seldom feels hungry. He is not
eating enough calories and protein, and his muscle
and fat tissue are disappearing. What is the likely
diagnosis of this condition?
Answer: This condition is called cachexia.
Question 2: A patient is trying to get pregnant. Her
physician recommends that she take folate (B9)
supplements. What is the purpose of these
supplements?
Answer: Taking folate as a fetus develops can
greatly reduce birth
defects
as neural tube 25
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Micronutrient Abnormalities
Trace Elements
Essential minerals needed for normal
physiologic functions
RDI is low; easy to obtain from normal food
consumption
Supplements are used mainly as additives to
enteral and parenteral nutrition formulas

Trace Elements: Chromium

Part of a complex of molecules that help
regulate glucose tolerance and insulin levels
Sources: canned foods, meat, fish, brown
sugar, coffee, tea,
whole
wheat
bread, rye
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Micronutrient Abnormalities
Trace Elements: Copper
Catalyst and coenzyme in various chemical
reactions
Without copper, RBCs and WBCs would decline
and cause anemia, leukopenia, neutropenia
Sources: organ meats, seafood, nuts, seeds,
wheat bran cereals, grains, cocoa
Indications: cases of deficiency (parenteral
nutrition)

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Micronutrient Abnormalities
Trace Elements: Iodine
Used to make thyroid hormones, which
regulate metabolic rates
Sources: seafood, seaweed; added to salt in
developed countries
Indications: cases of deficiency such as thyroid
conditions, radiation emergencies in which
radioactive iodides were used

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Micronutrient Abnormalities
Trace Elements: Iron
Iron is in hemoglobin of RBCs and in myoglobin
of muscle
Cofactor for neurotransmitter production; part
of the functional groups of many important
enzymes
Without iron, RBC production and oxygencarrying capacity are reduced
Sources: red meat, poultry, fish; in some
vegetables (but many cooking and storage
methods reduce its availability)
Indications: anemia (chronic disease and iron Paradigm Publishing, Inc.
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deficiency)

Micronutrient Abnormalities
Trace Elements: Manganese
Cofactor in many metabolic and enzymatic
reactions
Sources: legumes, seeds, tea, whole grains,
green leafy vegetables
Indication: cases of deficiency

Trace Elements: Selenium

Incorporated into amino acids; reduces
oxidative stress
Sources: broccoli, garlic, onions
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Indication: additive
parenteral nutrition

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Micronutrient Abnormalities
Trace Elements: Zinc
Cofactor in many physiologic processes,
including the synthesis of DNA and protein
Important role in immune function, wound
healing, blood clotting, reproduction, and
appropriate growth
Sources: meat, seafood, dairy products, nuts,
legumes, whole grains
Indications: cases of deficiency, immune
function booster, wound healing catalyst,
Wilsons disease
Indications (lozenges): symptoms of common
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cold

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Micronutrient Abnormalities
Trace Elements: Side Effects
Most side effects result from excess intake
Side effects mimic conditions of toxicity (see
Table 16.4)

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Enteral and Parenteral Nutrition

Nutritional Needs of Patients
Alternative ways to supply nutrition must be
used when a patient cannot be fed normally
Malnutrition will occur if a patient goes longer
than 7 to 10 days without food or nutrition

Enteral Nutrition
Feeding a patient through a tube into the GI
tract
Liquid nutrient is put through the tube in bolus
doses (mimics eating a meal) or continuously
with enteral pump
Indications: bowel
obstruction,
short gut
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Enteral and Parenteral Nutrition

Enteral Nutrition

(continued)
Indication: patients in long-term care who
cannot swallow food voluntarily due to stroke
or coma
IV fluids are usually given in addition to enteral
feeding to maintain hydration status
Technicians often order enteral feeding
formulas
Requirement: label enteral feeding
preparations with a warning not to
administer them through an IV
Enteral feeding is preferred to parenteral
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feeding; keepsthe
GI tract functional and

Enteral and Parenteral Nutrition

Enteral Tube
Feeding Sites
A manually inserted
NG tube is not
comfortable ; this
tube is used on a
short-term basis
A surgically placed
G tube or J tube
delivers enteral
nutrition via the
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stomach or

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Enteral and Parenteral Nutrition

Parenteral Nutrition
Often called TPN
Involves feeding a patient through an IV when
the digestive tract cannot be used
Used for severe burns, intolerance to enteral
feeding, anorexia nervosa, IBD, pancreatitis,
severe diarrhea
Sometimes used in pregnancy, AIDs, cancer
Supplies all needed fluids, electrolytes,
nutrients (carbohydrates, proteins, and fats),
vitamins, minerals
Technicians in specialty or home-infusion
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pharmacies mix TPN solutions

Enteral and Parenteral Nutrition

Mixing of Parenteral Nutrition Solutions
Order of mixing is important
Mix all clear ingredients before cloudy
ingredients
Add some electrolytes and trace minerals
separating to reduce precipitating out of
solution
Precipitates occur when minerals bind
together and form specks that could
block capillary flow
Add vitamins last, just before administration
Important to properly agitate and mix each
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TPN bag

Enteral and Parenteral Nutrition

Mixing of Parenteral Nutrition Solutions
(continued)
Two-in-one Contain proteins (amino acids) and
Mixtures
carbohydrate (dextrose)
Good for 21 days if refrigerated and
7 days at room temperature
Three-in Contain proteins, carbohydrates,
one
lipids (fats)
Mixtures
Lipids are cloudy; can hide
precipitates
Less stable solutions as two-in-one
Good for 7 days if refrigerated and
24 hours
at room temperature
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Obesity
About Obesity
The CDC estimates that approximately 34% of
adults in the United States are obese
Obesity in males: ABW is 25% or more above
IBW
Obesity in females: ABW is 35% or more
above IBW
Morbid obesity is when ABW is more than twice
IBW
Causes of obesity: environmental, genetic,
physiological, and psychological factors
Obesity is associated with serious health risks
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and mortality (see Table 16.5)

Obesity
About Obesity

(continued)
Centrally distributed fat is adipose tissue that
accumulates in the abdominal area vs. in the
hips, thighs, or buttocks
Linked to heart disease and diabetes
Obese people have more depression and
psychological disturbances

Drugs for Obesity

Preferred treatment for obesity is lifestyle and
dietary changes; changes must be permanent
to control weight
Indication (prescription):
BMI
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Inc. over 30 (or over 40

Obesity
Drugs for Obesity: Appetite Suppressants
Mechanism of Action: stimulate CNS; stimulate
dopamine and norepinephrine and prevent
reuptake of serotonin; signal sense of fullness
and satisfaction
Route: oral; all CNS stimulants are controlled
substances
Side Effects (common): headache,
stomachache, insomnia, nervousness,
irritability
Side Effects (other): difficulty urinating,
constipation
Inc.
Caution: do not Paradigm
take Publishing,
with other
drugs that also41

Obesity
Drugs for Obesity: Lipase Inhibitor
Mechanism of Action: prevents enzymes in the
intestines from breaking down fats into a form
that can be absorbed
Fat then passes through intestines out of the
rectum
Indication: patients who are overweight
Routes: all are oral
Side Effects (common): fatty or oily stools,
fecal incontinence or urgency, gas, diarrhea
Caution: potential vitamin deficiencies
Technicians can
help patients locate a
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Your Turn
Question 1: What is the reason enteral feeding is
preferred to parenteral feeding?
Answer: Enteral feeding keeps the GI tract
functional and prevents abdominal infections.
Question 2: A physician is writing an order for drug
therapy for a morbidly obese patient who wants to
lose weight. The patient is already taking an
antidepressant that works by increasing the amount
of serotonin in the brain. What drug therapy will not
be prescribed? Why?
Answer: An appetite suppressant will not be
prescribed. If taken with the antidepressant,
serotonin syndrome,
a serious side effect, could43
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result.

Herbal and Alternative Therapies

Fiber is a natural substance in fruits and
vegetables
Creates a sense of fullness and speeds GI
motility; this limits fat and calorie absorption
Produces laxative effects, lowers cholesterol,
promotes colon health
Ephedra (also known as ma huang) is banned
from sale in the United States
It is a CNS stimulant with anorexiant effects
Serious effects, and even death, occurred
from OTC use
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Summary
Estimate body composition by comparing ABW
to a calculated IBW or by determining BMI
Recommended daily intake values are
published for all vitamins and minerals
A lack of vitamins can cause illness
Toxicity can occur with excess of fat-soluble
vitamins or some minerals
Enteral and parenteral nutrition used for
malnutrition
Appetite suppressants and lipase inhibitors are
for obesity
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