 fats are transported into the bloodstream via the lymphatic circulation.

 fermentation produces short-chain fatty acids (SCFAs) and gas.

 Autonomic nerves – sympathetic – fear, pain; parasympathetic – smell, sight
 Ghrelin, a neuropeptide secreted from the stomach, and motilin, a related hormone
secreted from the duodenum, send a “hungry” message to the brain.
 Gastrin – increased acidity- increases gastric motility. Secretin – stimulates
pancreatic juice, inhibits, gastric acid.
 Major functions of CCK are to (1) stimulate the pancreas to secrete enzymes,
bicarbonate, and water; (2) stimulate gallbladder contraction; (3) increase colonic
and rectal motility; (4) slow gastric emptying; and (5) increase satiety.
 Motilin stimulate gastric emptying and intestinal migrating contractions - Combined
with antibiotic erythromycin to treat delayed gastric emptying. Somatostatin
decreases motility of the stomach and intestine and inhibits or regulates the release
of several gastrointestinal hormones – useful for disorders diarrhoea, short bowel
syndrome, pancreatitis, dumping syndrome, and gastric hypersecretion
 intrinsic factor (a glycoprotein that facilitates vitamin B12 absorption in the ileum) is
produced in stomach
 stomach pH 1 to 4
 the duodenum is approximately 0.5 m long, the jejunum is 2 to 3 m, and the ileum is
3 to 4 m.
 passive transport without energy and without any transport protein, with transport
protein facilitated diffusion.
 Active transport require energy and transport protein
 Reduced abundance or
 changes in the relative proportions of these beneficial bacteria, a state called
dysbiosis
 several nutrients are formed by bacterial synthesis, such as vitamin K, vitamin B12,
thiamin, and riboflavin.
 99% protin, 95% to 97% of ingested fat is absorbed,
 The absorption of zinc is impaired with disproportionately increased amounts of
magnesium, calcium, and iron.
 large amounts of iron or zinc may decrease the absorption of copper
 the presence of copper may lower iron and molybdenum absorption.
 Cobalt and iron compete and inhibits one other absorption
 Allostasis -This is a condition of metabolic stability with adjustments for
environmental influences and stresses through physiologic changes
 pro-inflammatory molecules - adipokines and cytokines
 “smoldering disease” – prolonged inflammation for longtime without noticeable
symptoms, finally comeup with tissue damage.
 inflammatory biomarkers, such as high-sensitivity C-reactive protein (CRP-hs)
(plasma), sedimentation rate, interleukin-6 (IL-6), and TNF-alpha - diseases well
characterized by these markers include heart disease, diabetes, autoimmune
diseases, and possibly cancer and Alzheimer’s disease
 Visceral adipose tissue (VAT) - endocrine functions - secretion of inflammatory
adipokines, such as resistin, leptin, and adiponectin, and tumor necrosis-factor-
alpha (TNF-alpha)—all contributing to the systemic total inflammatory load.
 “brown out” or “black out.”- problem with mitochondria (power plant)- problem
with ATP production – identified by coenzyme Q10 and alpha lipoic acid. (fatigue –
symptom of mitochondrial dysfunction to check macronutrient intake)
 study regarding diseases that are related to disturbances in the gut environment and
the immune system is called enteroimmunology.
 too sluggish and congested internal environment, facilitating the development of
chronic diseases such as cancer, cardiovascular disease, and infectious diseases
 Dietary factors helping to maintain healthy fluid viscosity are hydration, vitamin E
with significant gamma-tocopherol, polyunsaturated fatty acids (PUFAs),
monounsaturated fats (MUFAs), and avoidance of any chronic subclinical infections
and foods or substances that may act as antigens
 Common biomarkers of increased body fluid viscosity are blood fibrinogen with
platelets, and urinalysis measurements of specific gravity and the presence of
“cloudiness” or mucus.
 vitamin D, vitamin C, and methylation nutrients such as folate, B12, B6, and B2,
which act as co-nutrients in inflammation and immune-control mechanisms
 critical nutrient-partner balances are omega-6 and omega-3 fatty acids, vitamin D
and vitamin A, magnesium and calcium, and folate, B6, B2, and B12.
 Prostaglandins contribute to the regulation of vascular tone, platelet function, and
fertility.
 Omega 3 EPA eicosanoid - suppress arachidonic acid biosynthesis, an omega-6 fatty
acid (which increases inflammation when taken in excess)
 Omega 3 EPA and DHA -critical component - eye and brain - modulation of metabolic
inflammation.
 GLA not only attenuates intracellular inflammation by converting to DGLA but also
reduces inflammation in the extracellular matrix present in diabetic nephropathy
 AA should be balance with omega 3 intake if not excess AA can contribute to
increase inflammation and increase carcinogen cells
 GLA-rich plant oils from evening primrose, black currant, and borage
 CYP450(cytochrome P450) enzymes are expressed primarily in the liver, but they
also occur in the small intestine, kidneys, lungs, and placenta helps to remove toxins
 Vit D sources - fatty fish, fish eggs or caviar, organ meats, egg yolk, and mushrooms
 Mg – inhibition of inflammation – Mg nutrient partner Ca and Zn
 Zn nutrient partner Cu.
 In a nutrition-focused physical exam, white spots under the nails loss of appetite,
anorexia nervosa, loss of normal taste sensation, alopecia, hyperkeratinization of
skin, dermatitis, and reproductive abnormalities can indicate possible zinc
deficiencies.
 Methylation - Folate, B6, B2 and B12
 Flavonoids and anti- oxidant nutrients - protection against free radical and reactive
oxygen species
 Ascorbate interacts with the vitamin E complex to provide protection to water- and
lipid-soluble surfaces in membranes. glutathione, another water-soluble anti-
oxidant that is synthesized in all cells and which supports the central role of
ascorbate and vitamin E; lipoic acid with its water and lipid molecular components
and sometimes considered the “universal antioxidant”; and coenzyme Q-10 that
functions in protecting lipid structures, especially in cardiac muscle and
mitochondrial membranes.
 Ca 99% in bones and teeth only 1 % in ECF. Half of this is combined with albumin.
The Ca level will decrease in albumin(hypoalbuminemia)
 serum total calcium is about 8.5 to 10.5 mg/dl, whereas normal levels for ionized
calcium are 4.5 to 5.5 mEq/L.
 functions - regulates nerve transmission, muscle contraction, bone metabolism, and
blood pressure regulation and is necessary for blood clotting.
 Calcium is regulated by parathyroid hormone (PTH), calcitonin, vitamin D, and
phosphorus.
 20% to 60% of dietary calcium is absorbed- ileum site of absorption – passive
transport – excretion kidney – less due to protein bound – 100 to 200 mg. RDA –
1000 to 1300mg. upper limit – 2500 – 3000mg
 NA normal range of 135 to 145 mEq/L. About 90% to 95% of normal body sodium
loss is through the urine; the rest is lost in feces and sweat
 Sodium balance is regulated in part by aldosterone, a mineralocorticoid secreted by
the adrenal cortex
 Mg – normal level -.6 to 2.5 mEq/L. half of the body’s magnesium is located in bone,
whereas another 45% resides in soft tissue; only 1% of the body’s magnesium
content is in the extracellular fluids.
 Na RDA - upper limit of 2.3 g of sodium per day (or 5.8 g sodium chloride per day)
 Approximately 30-50% of magnesium ingested from the diet is absorbed (within the
jejunum and ileum though passive and active transport mechanisms)
 the kidneys increase potassium excretion in light of hypomagnesemia so it should be
corrected immediately
 Mg RDA – 310-420mg
 Ph – normal level 2.4 and 4.6 mg/dl. RDA – 700mg. upper limit of 3500 to 4000 mg
 Normal serum K - 3.5 to 5 mEq/L. Potassium-rich food sources include fruits,
vegetables, fresh meat, and dairy products. RDA - 4700 mg
 tetracycline or ciprofloxacin should be warned not to combine the drug with milk,
yogurt, or supplements containing divalent cations, calcium, iron, magnesium, zinc,
or vitamin-minerals containing any of these cations.
 probiotic contains the yeast Saccharomyces boulardii. It should not be used in any
patient with a central line for intravenous therapy, including those on dialysis.
 TJC requires that nutrition screening be completed within 24 hours of admission
 Sentinel events are unanticipated events that involve death, serious physical or
psychologic injury, or the risk thereof.
 Problem-oriented medical records (POMR), subjective, objective, assessment, plan
(SOAP), assessment, diagnosis, interventions, monitoring,
 evaluation (ADIME), electronic medical record (EMR), EHR, and personal health
record(PHR)
 U.S. Departments of Agriculture (USDA) and Department of Health and Human
Services (DHHS)
 Information about the diet and nutritional status of Americans and the relationship
between diet and health is collected primarily by the CDC via its NCHS and National
Health and Nutrition Examination Survey (NHANES).
 Natural medicine approaches known as Holistic medicine.
 chiropractic medicine for back pain, acupuncture for pain relief, select dietary
supplementation for conditions such as macular degeneration, depression, and
diarrhea
 nasogatric - short-term (no more than 3 to 4 weeks) - intolerance to gastric feeding-
Abdominal distention and discomfort, Vomiting, Persistent diarrhea. Risk - aspiration
pneumonia
 Gastrostomy or Jejunostomy - more than 3 to 4 weeks,
 The amount of protein in available commercial enteral formulas varies from 6% to
25% of total kilocalories – protein mostly from derived from casein, whey, or soy
protein isolate.
 Elemental formulas contain di- and tripeptides and amino acids, which are absorbed
more easily. Specialized formulas (for hepatic or renal failure or in cases of multiple,
severe allergies) may include crystalline amino acids.
 Specific amino acids may be added to some enteral formulas. Branched chain amino
acids are used in formulas for patients with severe hepatic disease, and arginine has
been added to formulas marketed for critically ill patients.
 CHO 30 to 85% calories. Hydrolyzed formulas contain carbohydrate from cornstarch
or maltodextrin.
 Fructooligosaccharides (FOS), which are prebiotics, have been added to enteral
formulas, often in combination with source of dietary fiber
 FOS in individuals with irritable bowel syndrome (IBS) may worsen symptoms
 Lipid 1.5 to 55% calories. corn, sunflower, safflower, or canola oil provides between
15% and 30% of the total kilocalories. limited fats are in the form of MCT.
 MCTs do not require bile salts or pancreatic lipase for digestion and are absorbed
directly into the portal circulation.
 Formulas intended for patients with renal or hepatic failure are intentionally low in
vitamins A, D, and E, sodium, and potassium.
 1 ml of water per kilocalorie consumed, or 30 to 35 ml/kg of usual body weight.
 Standard (1 kcal/ml) formulas contain approximately 85% water by volume;
concentrated (2 kcal/ml) formulas contain only approximately 70% water by volume.
 Formula expiry - 4-hour hang time for a product in an open system and 24 to 48
hours for products in closed system
 bolus enteral feedings for stable patient – 5 to 20 mins, 500mlper time, 3 to 4 time
per day. Intolerable reduce feed per time and increase frequency
 intermittent - daily feeding schedule is four to six feedings, each administered over
20 to 60 minutes. Formula administration is initiated at 100 to 150 ml per feeding
and increased incrementally as tolerated.
 Cyclic feeding – daily feeding schedule is 90 to 125 ml per hour of formula
administered over 18 to 20 hours
 Patients with a feeding tube tip in the small intestine should be fed only by
continuous or cyclic infusion
 Aspiration, a common concern for patients receiving EN, diarrhoea, constipation,
 PPN - up to 800 to 900 mOsm/kg of solvent can be infused
 peripherally inserted central catheter (PICC) may be used for short- or moderate-
term infusion
 PN solution amino acid - 3% to 20%. Protein - 15% to 20% of total energy intake
 Carbohydrates - dextrose monohydrate(3.4 calories per gram) - 5% to 70%
 carbohydrate administration should not exceed 5 to 6 mg/kg/min in critically ill
patients. Protein 15 to 20%, fat 20 to 30% remaining CHO as dextrose Excessive
administration can lead to hyperglycemia, hepatic abnormalities, or increased
ventilatory drive
 lipid - aqueous suspensions of soybean oil with egg yolk phospholipid as the
emulsifier.
 10% of calories per day from soybean – 2 to 4% of linoleic acid DV. Should not
exceed 2g /kg. 1 to 1.5 are common. TG should be monitored.
 1% - 1.1kcal/ml, 20% - 2kcal/ml. 20-30% provide 1g fat/kg.
 home parenteral nutrition - Alternative forms of lipids - Lipid sources other than
soybean or safflower oil including coconut, olive, and fish oil are used. 80% olive oil
+20% soyabean oil – 2kcal/ml.
 soybean oil, medium-chain triglycerides, olive oil, and fish oil (SMOF lipid) – safe and
efficacious than std soyabean oil emulsion.
 Monitoring of manganese and chromium status is recommended for PN patients
 Iron, as it is not compatible with lipids, given separately.
 PN should be started below needed and then increased to need on 2 or 3 days,
some may do this with dextrose infusion of 100 to 200mg and then reach max need
on 2 or 3 days. In case of need to stop PN, the rate should be reduced gradually to
stop. Sudden stop may cause hypoglycemia.
 Continuous infusion 24 hrs for critically ill hosp patients, cyclic infusion 12 to 16hrs
for life long patients (homePN)
 transition from PN to EN, introduce a minimal amount of enteral feeding at a low
rate of 30 to 40 ml/hr to establish gastrointestinal tolerance. If tolerated PN can be
reduced gradually and EN rate increase by 25 to 30 ml every 8 to 24 hrs. if 75%
tolerated PN can be discontinued. Formula will be low in lipids and lactose free
 PN to oral, feed should be liquid and diet low in fat, low in fiber, easily digestible and
lactose free.
 EN to oral – co tenuous feed to 12 hrs to 8hrs during night then to liquid, diet if not
compatible both EN and oral
 Oral supplements – 250kcal/8oz or 240ml, 8 to 14g protein, 350-500 to 540kcal
 Oral supplements that contain hydrolyzed protein and free amino acid are
developed for patients with renal, liver, malabsorptive diseases
