Gizi Normal, Atlit,

dan Pasien
Yoseph Samodra
FK UKDW
September 2018
 Energy and Nutrient Needs During
Childhood
• Energy and Protein
– Total energy requirements gradually increases
– Kilocalories and grams protein per kg of body
weight decreases from infancy

• Vitamins and Minerals

– Variety of foods needed
– Assess iron intake

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Influences on Childhood Food Habits
and Intake
• Toddler’s food habits are usually temporary
• Idea is to promote self-regulation of energy
intake.
– Caregivers have increased role in the development
of child’s health and nutrition habits  safe,
sanitary, and supportive environment.
– Kids are responsible for when and how much to
eat.
• External factors: TV, environment

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutritional Concerns of Childhood
1. Malnutrition and hunger
– Food insecurity: people who take in enough
calories but have diets of reduced quality that do
not met all daily requirements.

– Solution:
• Assistance programs
• Education

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrition Concerns of Childhood
2. Food and behavior
– Caffeine in soft drinks and energy drinks make
children jittery and interfere with sleep.
– Foods associated with hyperactivity
• Definition: a maladaptive and abnormal increase in
activity that is inconsistent with developmental levels.
– Attention-deficit hyperactivity disorder (ADHD)
• No solid proof that ADHD is associated with sugar
• Food preservatives and colorings may enhance
hyperactive behaviors (further research needed)

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrition Concerns of Childhood
3. Childhood overweight/underweight/stunting
– ~32% of American children age 2-19 years are
overweight or obese
– Programs designed to treat childhood obesity
generally provide behavior modification and
exercise counseling, instead of restricting caloric
intake or food choices.
– Indonesia: underweight and stunting is still high
– Solution?

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Figure 13.4 Factors that contribute to childhood obesity
Childhood obesity is on the rise, and it predisposes
children to health problems when they become adults.

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrition Concerns of Childhood
4. Nutrition and chronic disease
– Eating with adults (transfer of eating habit)
• Infants/Toddlers need fat in their diet for growth, organ
protection, and CNS development
• Children 2+ should consume diet lower in fat, saturated
fat, and cholesterol to reduce risks for chronic diseases.
– Dietary Guidelines for Americans
• AAP recommends screening children with family history
of high lipid levels

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrition Concerns of Childhood
5. Lead toxicity
– Can lead to:
• Slow growth
• Iron-deficiency anemia
• Damage to brain and CNS
– Low iron, calcium, and zinc intakes increase lead
absorption

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrition Concerns of Childhood
• Vegetarianism
– Nutrients to emphasize
1. Calcium
2. Iron
3. Zinc
4. Vitamin B12
5. Vitamin D

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Adolescence
• Physical growth and development
– Height:
• For girls: begins between 10-11yrs
– 6 inches in height, 35 lbs in weight
1. Peak one year before menarche
2. 2-4 inches during the remainder of adolescence

• For boys: begins between 12-13 yrs

– 8 inches in height, 45 lbs in weight
– Thus, an malnourished adolescent may not
achieve his/her full potential height when growth
period is over.
From Childhood through Adulthood Nutrition. www.napavalley.edu
 Adolescence
• Physical growth and development
– Changes in body composition
• Boys: increase in lean body mass
• Girls: increase in body fat
–Changes in emotional maturity
• Psychological development affects food
choices, eating habits, body images.

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrient Needs of Adolescents
• Energy and protein
– Highest total calories and
protein grams per day than
at any other time of life
(exception of pregnancy
and lactation)
• Vitamins and minerals
– Nutrients of concern:

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Figure 13.7 Factors that influence adolescent food
choices
Social, cultural, psychological factors, especially
peer pressure, strongly influence adolescent food
choices.
From Childhood through Adulthood Nutrition. www.napavalley.edu
 Nutrition-Related Concerns for
Adolescents
1. Fitness and Sports
– Can provide catalyst for learning about nutrition and
improve daily habits
2. Acne
– Investigating the connections between diets and
acne
3. Eating disorders
– Becomes preoccupied with weight, appearance, and
eating habits.
– Not just a “girl’s problem”

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrition-Related Concerns for
Adolescents
4. Obesity
Risk factors:
– Developing high blood pressure
– Abnormal blood glucose tolerance and type 2
diabetes
– Breathing problems, joint pain, and heartburn.

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrition-Related Concerns for
Adolescents
5. Tobacco, alcohol, recreational drug
– Period of experimentation
– Alcohol and drug use may take priority over
adequate food intake
– Teens who use drugs are usually underweight
and report poor appetites

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Staying Young While Growing Older
• Age-related changes
– Weight and body composition
• Add fat; lose lean body mass
• Overweight/obese  chronic diseases
• Underweight  cardiovascular disease and
osteoporosis
– Physical activity
• Loss of lean body mass
• Regular physical activities reduces disease risk and
improves mental health.

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Staying Young While Growing Older
• Age-related concerns (cont.):
– Immunity
• Decline in defense mechanisms around 40-50 yrs old
• Increased risk for urinary tract infections, upper
respiratory illness (pneumonia, influenza)
– Taste and smell
• Decline in sensitivity  thus, increases intake foods
high in salt.
• Better to serve foods with stronger flavors and odors
over bland food.

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Staying Young While Growing Older
• Age-related concerns (cont.):
– Gastrointestinal changes
1. Reduced saliva production  ineffective chewing and
swallowing
2. Reduced acid secretion (HCl and pepsin)  less
efficient food digestion and allow the development of
atrophic gastritis  interfere with B12 absorption
3. Reduced GI motility

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrient Needs of the Mature Adult
• Energy
– Reduced calorie needs
– Physical activity increases energy requirements
while also helping to delay some loss in lean mass.
• Protein
– Same needs per kg body weight as younger adults

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrient Needs of the Mature Adult
• Carbohydrate
– 45-65% of calories in diet (high-carb)
– Fiber  prevents constipation and diverticulosis,
reduce risk for diabetes, promote healthy body weight
• Fat
– Maintain a moderate low-fat diet
• Water
– Reduced thirst response  dehydration
– Fluid recommendations are same as younger adults

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrient Needs of the Mature Adult
• Vitamins of concern
– Vitamin D
• Needed for bone health, calcium balance  if not,
osteoporosis
• Aging skin and tissues  reduced skin synthesis and
activation of vitamin D
• Higher needs compared to younger adults
– B vitamins
• Reduced ability to absorb B12
• Focus on Folate, B6, B12
• Should consume more fortified foods and supplements

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrient Needs for Mature Adults
• Antioxidants
– Found in fruits and vegetables
– Important to reduce oxidative stress and
degenerative diseases such as cataracts,
Alzheimer, and macular degeneration.
– May protect against damage to the brain

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrient Needs of the Mature Adult
• Minerals of concern
– Calcium: Bone health
– Zinc: Immunity and wound healing
• Marginal deficiencies likely
• Avoid excess supplementation
– Iron
• Elders may have limited intake

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Figure 13.16 Micronutrients of particular concern for
older people
As we age, our energy needs decline, but our vitamin and mineral needs remain
stable. This makes nutrient-dense foods especially important for older adults.

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrition-Related Concerns of Mature
Adults
1. Drug-drug and drug-nutrient interactions
– Can affect use of drugs or nutrients
– Herbal supplements, vitamins and minerals
supplementation in high doses should be viewed as
drugs
– Possible interactions should be identified and avoided
2. Depression
– Common among institutionalized and low-income
seniors
– May reduce food intake
– Alcoholism can interfere with nutrient usage
From Childhood through Adulthood Nutrition. www.napavalley.edu
 Nutrition-Related Concerns of Mature
Adults
3. Anorexia of aging
– Loss of appetite with illness
– Can lead to chronic malnutrition
4. Arthritis (pain and swelling in joints)
– May interfere with food preparation and eating
– Medications may interfere with nutrient
absorption
– Managing weight and dietary changes may
improve symptoms

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrition-Related Concerns of Mature
Adults
5. Bowel and bladder regulation
– Increased risk of urinary tract infection
– Chronic constipation more common with age

6. Dental health
– Tooth loss, difficulty swallowing, and mouth pain
may interfere with eating ability or food choices

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrition-Related Concerns of Mature
Adults
7. Vision Problems
– Can affect ability to shop and cook
– Antioxidants may reduce macular degeneration

8. Osteoporosis
– Common in elders, especially women
– Maintain calcium, vitamin D, and exercise

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrition-Related Concerns of Mature
Adults
9. Alzheimer’s disease – accumulation of
plaques in certain regions of the brain and
degeneration of a certain class of neurons
– Affects ability to obtain, prepare, and consume an
optimal diet.
– Reduced taste and smell
– Risk for weight loss and malnutrition

From Childhood through Adulthood Nutrition. www.napavalley.edu

 Nutrition Can Significantly
Improve Athletic Performance

Amy Boltz. Sports Nutrition: Enhancing Athletic

Performance.
www.haverfordsoccer.org/docs/Coaches/Health
 Why is Nutrition Important?
• Good nutrition is essential to:
– Preserve and build muscle
– Maintain healthy bones
– Maximize oxygen transport and use
– Repair existing cells and create new tissue
– Maintain optimal fluid and electrolyte balance
– Provide energy

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 What is important?
Healthy Food Choices

Adequate Fueling

Hydration

Understanding supplements

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 What is the Best Diet for Athletes?
• A well balanced diet that includes variety

Carbohydrates
~30% ~55%
Protein
~15%
Fat

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 The Food Guide Pyramid
Fats & Sweets: sparingly

Dairy: 2-3 Meat: 2-3

Vegetables: 3-5 Fruits: 2-4

Grains: 6-11

Following the Food Guide Pyramid will help

achieve a well balanced diet

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 Energy…What is it and Where does it
come from?
• Energy is the ability to perform work

• Energy comes from food and is measured in

calories

• Calories come from:

• Carbohydrate
• Protein
• Fat

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 The Best fuel for our muscles
is Carbohydrates!!

High carb foods are grains, fruits,

vegetables, dairy, and beans
Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.
 Carbohydrates
• Stored as glycogen in the muscles
– Preferred/ Major source of energy
– Broken down rapidly
– Important in maximal exercise
• Carbohydrates also:
– Power muscle contraction
– Provide fuel for the brain
– Aids in fat metabolism
– Protein sparing effect
• Allows protein to be used for tissue maintainence/repair verses
energy
Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.
 Training Diet
Eat a high carb diet of 275-350 grams/day
Food Grams of Carb
1/2 cup pasta 20
1 slice of bread 13
Large baked potato 30-50
Banana 27
1 cup low-fat milk 12
1 cup of most beans 40-45

Above Numbers are based on a 2,000 calorie diet.

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.
 What happens when Carbohydrate
intakes are low?

• Decreased athletic performance

• Muscle loss (protein used for energy)
• Fatigue
• Nutrient deficiency
• Irritability

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 What about Protein?
• Role in the body
– Tissue maintenance
– Tissue repair
– Tissue growth
– Energy source (to a lesser degree)

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 How much Protein Do I need?
• Most athletes in heavy training need 1.0-1.8
grams per kilogram body weight.
Body weight Protein
gram/day
100 lb 59 g
120 lb 71 g
140 lb 83 g
160 lb 95 g
180 lb 106 g

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 How can I meet my protein needs?
• Food is the best source of protein
• High protein foods include:
– Meats
– Dairy products
– Nuts
– Beans
• Most Americans eat more than the
recommended amount of protein
– Protein supplements are not necessary

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 How much protein is in my food?
Food Grams of
Protein
4 oz chicken or steak 33 g
1 large hamburger 22 g
1 cup mixed nuts 23 g
2 eggs 12 g
2 Tbsp peanut butter 8g
1 cup milk 8g
1 slice of cheese 7g
Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.
 Pre-Competition Meals
Goal: To provide adequate carbohydrate energy
and optimal hydration

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 Eat to Compete
 It takes 1- 4 hours for food to
leave your stomach
 High Carb foods are digested
quickly
High Protein foods can increase
water requirements
Foods high in Fat can stay in your
stomach for more than 4 hours

Best choice for pre-game meals is something high in

Carbs - easy to digest and becomes quick energy !

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 Pre-Competition Meals
Time before Calories Your weight # of calories
exercise needed per (pounds) you need to
pound of eat before
weight practice
1 hour 2
2 hours 4
3 hours 6 X ______ lbs = _____ cal.
4 hours 8
You have 3 so… 6 140 lbs = 840
hours times calories

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 What and When should I eat
after I Workout?
• In the first 30 minutes:
– Replace fluids and electrolytes
– Eat high-carbohydrate foods
• Examples: Banana, Yogurt, Granola Bar
• Within 2 hours:
– Drink 2-3 cups of fluid for every pound lost
– Eat a high-carbohydrate meal with some protein
• Example: Ham Sandwich, Rice and Beans

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 Hydration
The best way to stay
well hydrated for
exercise is to drink
• Before
• During
• After

Remember! Drink regardless of

whether you are thirsty or not!

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 How much do I drink and when ???
Way Before Right During After
Before
Drink 2-3 Drink 1 cup Drink 1 cup Drink at least
cups of fluid of fluid 10 to of fluid every 2 cups for
2 to 3 hours 30 minutes 15 minutes every pound
before before of lost weight
playing playing

Every 15 For every

minutes pound of
lost weight

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 How will I know if I am becoming
dehydrated?
• Warning Signs:
– Headache
– Fatigue
– Confusion
– Nausea
– Muscle Cramps
– Dizziness
– Decreased stamina, speed, energy, muscle strength

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 Supplements:
Helpful or Harmful?
• Supplements can be dangerous
• No one know exactly what many supplements
do
• High intakes can be extremely dangerous
• There is a lack of research on their
effectiveness
• They can be expensive

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 A Better Alternative to Supplements
• Train hard
• Eat enough to support your training
– Eat an extra 500-1,000 calories per day
– Eat a variety of foods from all food groups
– Eat several small meals and snacks every day
– Remember Carbs are most important
• Natural foods are best!

Amy Boltz. Sports Nutrition: Enhancing Athletic Performance.

 Malnutrition?
What is malnutrition?
 Malnutrition = imbalance between nutritional intake

and nutritional requirements.

 Malnutrition in the UK costs in excess of 7.3 billion

Who is at risk of malnutrition?

 A malnourished patient can  their length of stay in

hospital by 50%
 75% of patients may  weight during admission

 A large proportion of patients are at risk

Laura Haigh. The Importance of Nutrition. www.nhsggc.org.uk

 Why might patients become
undernourished?
 Decreased food intake

 Increased nutritional/energy
requirements

 Decreased nutrient absorption (diseases

affecting the gastro-intestinal tract)

Laura Haigh. The Importance of Nutrition. www.nhsggc.org.uk

 What are the consequences of
malnutrition?
→ Illness
→ Reduced food intake

→ Reduced muscle strength

→ Decreased mobility

→ Impaired immunity
→ Susceptibility to wound/chest infection

→ Apathy
→ Depression

Laura Haigh. The Importance of Nutrition. www.nhsggc.org.uk

 Identifying patients at
nutritional risk
Nutritional screening
 Identifies patients who are or at risk of
becoming undernourished
 Action plan

1. identifies appropriate strategies of care

2. identifies responsibilities for care
 Not all patients identified as being at
risk require being seen by a dietitian
Laura Haigh. The Importance of Nutrition. www.nhsggc.org.uk
 Role of the dietitian
 The dietitian is an expert in nutrition
 Assess more high risk patients
 Assess nutritional status
 Estimate nutritional requirements
 Give appropriate nutritional advice
 Request prescription products if appropriate
 Discuss care plans with multi disciplinary teams
to ensure implementation

Laura Haigh. The Importance of Nutrition. www.nhsggc.org.uk

 Catering system
 Dietitians will inform nursing staff of
specific dietary requirements and
appropriate texture modified diet
 All meals are ordered by nursing staff
 Fortified foods and additional snacks can
be arranged via the dietitian

Laura Haigh. The Importance of Nutrition. www.nhsggc.org.uk

 Benefits of Nutritional Support
Patient Benefits BPJSK Benefits
 ↓ Length of stay  Cost savings

 ↓ Rehab time

 ↓ Mortality

 ↑ Quality of life

Laura Haigh. The Importance of Nutrition. www.nhsggc.org.uk

 Why weigh?
 Weight is an essential component of
assessing nutritional status

 Weight history highlights changes of

significance

 Unexplained weight loss should be

investigated
Laura Haigh. The Importance of Nutrition. www.nhsggc.org.uk
 How should weights
should be obtained?
 Weekly weights (unless otherwise instructed)
 Obtain using the same scales preferably
 Ensure patient wearing similar clothing
 Weights should be recorded in the medical
records
 If weight has significantly changed
 Re-check the weight
 Inform the concerned personnel
Laura Haigh. The Importance of Nutrition. www.nhsggc.org.uk
 Methods of providing
Nutritional Support
 Appropriate food choices/↑ no. of
meals/snacks
 Fortify foods to ↑ their nutritional value
 Provide supplement drinks
 Enteral nutrition
 Parenteral nutrition

Laura Haigh. The Importance of Nutrition. www.nhsggc.org.uk

 Nutritional Supplements
 Some can not meet their nutritional
needs through oral diet alone

 Supplement drinks may be indicated

 Prescription products

should only be given to patients as

directed by medical or dietetic staff
Laura Haigh. The Importance of Nutrition. www.nhsggc.org.uk
 Starvation and ICU
 Complex metabolic changes
 Weight loss is high if sick patients are not fed
 But nutrients are not always adequately absorbed or
metabolised

 Weight loss occurs despite feeding

 Important to feed patients but with regard to their
individual needs and complexities.

Nutrition in Sick Patients. www.scottishintensivecare.org.uk

 ICU nutrition
 Used to be everything mixed up and given via NG tube
 Risk of infection
 Now specialised feeds are used in sterile packaging

Nutrition in Sick Patients. www.scottishintensivecare.org.uk

 Overfeeding
 Lactic acidosis
 Hyperglycaemia
 Increased infections
 Liver impairment (Alk phos, ALT, GGT, acalculous
cholecystitis)

 Persistent pyrexia

Nutrition in Sick Patients. www.scottishintensivecare.org.uk

 Complex nutrition: Monitoring
 Urea, Creat, Electrolites
 Phosphate, calcium, magnesium
 Glucose
 LFTs
 Fluid balance
 Haematology
 Weight
 Trace elements if long-term

Nutrition in Sick Patients. www.scottishintensivecare.org.uk

 ‘Do not let your patients starve and when
you offer them nutrition support, do so by
the safest, simplest, most effective route.’

Dr Mike Stroud Feb 2006

Chair of NICE committee

Nutrition in Sick Patients. www.scottishintensivecare.org.uk