Sports Nutrition Health Effects

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Sports Nutrition Health Effects

    Nutrition Support

Module Objectives:

    ? Explain the alterations in energy metabolism in stress and starvation.

    ? Assess energy requirements of patients during stress and starvation.

    ? Summarize feeding routes, indications, and risks for patients who cannot eat.

    ? Describe the consequences of bypassing the gut during feeding.

    ? Outline the pathophysiology and treatment of refeeding syndrome, and identify

    patients at risk.

Module Outline:

    Getting Started

    Module Objectives

    Gut Nutrition

    GI Tract and Metabolism

    Normal and Altered Intestine

    GI Hormone Response


    Glutamine Metabolism in Stress

    Sources of Glutamine

    Short-Chain Fatty Acids

    Feeding Route

    Feeding Route

    Importance of Enteral and Parenteral Nutrition

    Enteral and Parenteral Feeding

    Nutrient Transport with Oral or Enteral Feeding

    Nutrient Transport with Parenteral Feeding

    Energy Expenditure

    Components of Energy Expenditure

    Basal Energy Expenditure and Thermic Effect of Food

    Growth and Lactation

    Physical Activity

    Body Composition in Non-Obese Individuals

    Body Compartments



    Indirect Calorimetry


    Respiratory Quotient

    Indirect Calorimetry: Sample Calculation

    Nutrition Support Handouts 1

Energy Assessment


    Prediction Equations

    Hypermetabolism and Fever Refeeding Syndrome

    Pathophysiology of Refeeding Syndrome

    Patients at Risk for Refeeding

    Preventing Refeeding Syndrome TPN


    Short-Bowel Syndrome

    Complications of Long-Term TPN Enteral Feeding



    Nutrition Plan

    Nutrition Assessment

    The Nutrition Plan

    Under- or Overfeeding

    Feeding Route

    Integrated Practice (Nutrition Support)

Nutrition Support Handouts 2

    Objectives, Key Concepts, and Key Concept Summaries by Topic

Topic: Gut Nutrition


    Explain the effect of feeding via the GI tract on metabolism.

Key Concept:

    Bypassing the gut by feeding intravenously alters the structure and function of the gastrointestinal tract.

    Food in the stomach stimulates gastrin secretion and gastric acid production. The presence of food and a low pH in the duodenum causes cholecystokinin (CCK) secretion and secretin stimulation. Parenteral feeding bypasses the GI tract and therefore does not stimulate secretion of intestinal hormones. Absence of CCK secretion can stop bile flow (cholestasis). With parenteral feeding, changes in the intestinal mucosa can occur. Over time, intestinal atrophy may allow bacteria and toxins to enter the bloodstream and may impair nutrient absorption. Glutamine, a conditionally essential amino acid, is an important oxidative fuel for the intestinal mucosa. During stress the demand for glutamine may exceed the supply. Inadequate supplies of glutamine can result in deterioration of the mucosal barrier.


Topic: Feeding Route


    Describe feeding routes for patients who cannot eat.

Key Concept:

    Patients who cannot eat should receive enteral or parenteral nutrition.

    Nutrition can be provided through alternate routes, such as enterally (into the stomach or small intestine) or parenterally (into a central or peripheral vein). When the GI tract is not functional, patients should be fed parenterally. In such cases, enteral feeding should begin as soon as ability to digest and absorb nutrients resumes, even if the majority of nutrition is provided parenterally. Patients with normal lower GI function, but who cannot swallow or maintain adequate oral intake should be fed enterally. Appropriate nutrition decreases length of hospital stay, reduces the risk of post-op complications, and improves wound healing. There are metabolic consequences to intravenous feedings because it bypasses the normal absorption and transport processes-- intravenous lipids enter the circulation as droplets without the apoproteins found on chlyomicrons.


Nutrition Support Handouts 3

Topic: Energy Expenditure


    Describe the components of and factors that influence total energy expenditure.

Key Concept:

    Basal metabolism, physical activity, and thermic effect of food comprise total energy expenditure in healthy individuals.

    Total energy expenditure has three components: basal metabolic rate (BMR), physical activity, and diet-induced thermogenesis (thermic effect of food). BMR represents the energy used by the body in a restful, awake state. This is the energy needed for ion pumping, protein synthesis, and all homeostatic functions. BMR depends mainly on body size and composition. Understanding body composition is important to clinical assessment of nutritional status. In both stress and malnutrition, body composition is altered because of loss of protein mass. Energy expenditure increases in stressed patients; the amount of increase depends upon the degree of illness. Changes in nutritional recommendations are concurrent with changes in body composition. Physical activity is the most variable component of total energy expenditure in healthy individuals.


Topic: Calorimetry


    Specify how indirect calorimetry can be used to estimate energy expenditure.

Key Concept:

    Indirect calorimetry can be used to estimate energy expenditure by using the respiratory quotient.

    Indirect calorimetry is a method of estimating energy expenditure based on CO2 production and O2 uptake. It is often used in a clinical setting to get a reliable estimate of energy expenditure and prevent over- or under-feeding of critically ill, malnourished, or extremely obese patients. A metabolic cart can take the measurements, determine the respiratory quotient (RQ; ratio of CO2 to O2), and convert the RQ into estimated expenditure. The equations for the oxidation of carbohydrates and fats show that known amounts of O2 and CO2 correspond to predictable amounts of energy production. Because glucose and fat are completely oxidized, energy production from glucose or fat oxidation can be predicted by measuring consumption of oxygen and production of carbon dioxide. Protein oxidized can be calculated from urinary nitrogen excretion.


Nutrition Support Handouts 4

Topic: Energy Assessment


    Describe how energy needs may be estimated in clinical settings.

Key Concept:

    Standardized prediction equations exist for estimating energy expenditure but have limited usefulness in critically ill patients.

    Indirect calorimetry is a reliable method for determining an individual’s energy expenditure, but it is not always feasible in clinical practice. Many standardized formulas exist to estimate energy expenditure based on a patient’s age, height, weight, and physical

    activity level. Many of these, however, were developed for healthy people and thus are not appropriate for critically ill patients. Furthermore, during stress, hypermetabolism and fever cause energy needs to increase. Stressed patients have high energy expenditures and increased protein turnover due to the hypermetabolism characteristic of the stress response. Hypermetabolism increases with severity of the trauma. With many diseases and traumas, fever is also present. Each degree rise in temperature above 37 degrees C elevates metabolic rate by about 10%.


Topic: Refeeding Syndrome


    Outline the pathophysiology and treatment of refeeding syndrome, and identify patients at risk.

Key Concept:

    Refeeding syndrome is characterized by metabolic events that occur upon feeding severely malnourished patients.

    Refeeding syndrome can occur with any type of feeding following a period of nutritional deprivation. Glucose moves into cells, and along with it, phosphorous, potassium, and magnesium, causing the serum concentrations of these minerals to drop abruptly. The severe mineral and fluid imbalances that occur with refeeding can lead to cardiac arrest, neuromuscular complications, or respiratory dysfunction. Malnourished patients with poor nutritional stores due to limited intake (i.e. anorexia nervosa, elderly patients with depression or dementia, cancer cachexia, malnutrition due to hunger, stress, or fasting) are at-risk. Refeeding syndrome can be prevented by avoiding sudden overfeeding, avoiding excess glucose, replacing phosphorus, magnesium, and potassium, restricting fluid intake, initiating sodium administration slowly, and providing thiamin.


Nutrition Support Handouts 5

Topic: TPN


    List three complications that can occur from long-term parenteral feeding.

Key Concept:

    Complications can occur from long-term parenteral feeding.

When nutrition is provided directly into the bloodstream, determining the patient’s

    nutritional needs as accurately as possible becomes critically important. Short-bowel

    syndrome is one condition that may require long-term parenteral feeding. Parenteral

    feeding is not without risk. Catheter-related infection, metabolic bone disease, liver

    disease, and micronutrient deficiencies are serious risks of long-term parenteral feeding.


Topic: Enteral Feeding


    Describe complications that can occur with enteral feeding.

Key Concept:

    Enteral feeding is not without risks..

When nutrition is provided directly into the GI tract, determining the patient’s nutritional

    needs as accurately as possible becomes critically important. Enteral feeding can lead to

    reflux of stomach contents into the lungs, which can lead to aspiration pneumonia.

    Diarrhea can be a common problem in enterally fed patients. Other serious problems may

    include refeeding syndrome, or altered glucose, lipid, or acid-base balance.


Nutrition Support Handouts 6

Topic: Nutrition Plan


    Characterize the factors considered in formulating a nutrition plan.

Key Concept:

    Formulating a nutrition plan is essential in the care of critically ill patients.

Nutrition assessment provides a picture of the patient’s nutritional risk. This requires

    collecting and evaluating information obtained from the patient’s history, physical exam,

    anthropometric measurements, and labs. From the information obtained in the nutritional

    assessment, a plan for the patient is formulated. The plan must be individualized to meet

    the patient’s requirements for protein, energy, and other nutrients. It should also include

    the goals for nutritional intake, and the most appropriate route of feeding and formula

    composition to achieve those goals. In the stressed patient, the goal is usually to prevent

    further depletion of lean body mass. Underfeeding can result in poor wound healing,

    weakness, and malnutrition as protein is used as an energy source. Overfeeding can result

    in hyperglycemia, carbon dioxide retention, and fatty liver.


Nutrition Support Handouts 7


American Dietetic Association’s Nutrition Care Manual,, accessed 10 October, 2006.

    ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients.JPEN J Parenter Enteral Nutr. 2002 Jan-Feb;26(1 Suppl):1SA-138SA.

    Berger MM, Spertinini F, Shenkin A, Wardle C, Wiesner L, Schindler C, Chiolero RL. Trace element supplementation modulates pulmonary infection rates after major burns: a double-blind, placebo-controlled trial. Am J Clin Nutr 1998;68:365-371

    Biffl WL, Moore EE, Haenel JB. Nutrition support of the trauma patient. Nutrition 2002;18:960-965

    Boitano, M. Hypocaloric feeding of the critically ill. Nutr Clin Pract. 2006 Dec;21(6):617-22.

    Brehm BJ, Spang SE, Lattin BL, Seeley RJ, Daniels SR, D’Alessio DA. The role of energy expenditure in the differential weight loss in obese women on low-fat and low-carbohydrate diets. J Clin Endocrinol Metab. 2005 Mar;90(3):175-82. Epub 2004 Dec 14.

    Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride.Institute of Medicine, National Academy Press, Washington, DC. 1997. Available

    Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients).Institute of Medicine, National Academy Press, Washington, DC. 2005. Available

    Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Institute of Medicine, National Academy Press, Washington, DC. 2005. Available

    Ehrlich HP, Tarver H, Hunt TK. Effects of vitamin A and glucocorticoids upon inflammation and collagen synthesis. Ann Surg 1973;177:222-227

    Hoffer LJ. Protein and energy provision in critical illness. Am J Clin Nutr 2003;78:906-11.

    Levine JA. Nonexercise activity themogenesis(NEAT): environment and biology. AM J Physiol Endocrinol Metab 2004;286:E675-E685.

Nutrition Support Handouts 8

    Kattlemann et al, Preliminary evidence for a medical nutrition therapy protocol: enteral feedings for critically ill patients. J Am Diet Assoc. 2006 Aug;106(8):1226-41. Review.

    McClain CJ, Twyman DL, Ott LG, Rapp RP, Tibbs PA, Norton JA, Karsakis EJ, Dempsey RJ, Young B. Zinc supplementation is associated with improved neurologic recovery rate and visceral protein levels of patients with severe closed head injury. J Neurotrauma 1996;13:25-34

McCray S, Walker S, Parrish CR. Much Ado About Refeeding. Practical

    Gastroenterology January 2005; series #23:26-44.

    Todd SR, Kozar RA, Moore FA. Nutrition support in adult trauma patients. Nutr Clin Pract. 2006 Oct;21(5):421-9.

Nutrition Support Handouts 9

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