NUTRIONAL CARE IN

TROPISM DISEASE

AGUSSALIM BUKHARI
Nutrition Department
Faculty of Medicine
2008
Hypercatabolic state in Infectious
Disease
- Induced by endogenous production of
variety of mediator respons to diverse
stimuli including spesific advance
disease
- Characterized : hypermetabolism & implies a
disruption of normal metabolic homeostasis

• Metabolic response  disease

- Energy expenditure
- Protein metabolism
- Glucose metabolism
- Lipid metabolism
o Energy expenditure
- Increased energy exp by the body as
well as increased metabolic rate
- TBO consumption increases because
of increased oxidation of fuel source
( These reaction produce heat 
increased heat  increased metabolic
rate )
- Increased minimally 15-25%
o Protein metabolism
- It provide amino acids that can serve as
substrate for protein synthesis
- The released amino acid can be converted
to glucose by the liver as an energy source
during the hypermetabolic response
- It provide a source of glutamine to be use
as a fuel source by the gut and possibly by
other tissue involved in the metabolic
response to stress
o Glucose metabolism
- Hyperglycemia is a commom
response ( increased hepatic
gluconeogenesis and decreased
glucose uptake
- HIV/AIDs  Hyperglycemia
???? ( pentamidine toxicity )
o Lipid metabolism
- Major source of fuel the body
representing 80% of the body energy
reserves
- Increased lipid oxidation
Systemic and organ reaction

• Gastrointestinal tract
- Provides important nutrient
absorptive and metabolic
function
- The intestine may partially
regulate the immune response
of disease
• Cahexia
- Hypermetabolic response may result
in cachexia if it is allowed to proceed
unabated
- Multiple mechanism appear to be
involved of cachexia :
anorexia, decreased physical activity
decreased secretion host anabolic
hormone, and altered host metabolic
response with abnormalities in protein,
lipids, carbohydrate metabolism
Tabel di bawah ini akan menunjukkan
kehilangan berat badan sesuai dengan lama
penyakit yang diderita

Waktu Significant Severe loss

loss wt % of wt % of
change change
1 minggu 1–2 >2
1 bulan 5 >5
3 bulan 7.5 > 7.5
6 bulan 10 > 10
• Dapat dihitung menggunakan rumus Harris-
Benedict sbb:
Laki-laki : BEE=66 + 13.7W + 5H – 6.8A
Perempuan : BEE=655 + 9.6W + 1.7H – 4.7A
• Untuk mendapatkan hasil yg akurat perlu
diperhitungkan aktivitas dan injury factor:
• Aktivitas faktor: 1.2 pt bedrest
1.3 ambulatory pt
1.5-1.75 mormal pt
2.0 extremely active
• Injury factor 1.2 minot operasi
1.35 skeletal trauma
1.44 elective operasi
1.6-1.9 major sepsis
1.88 trauma + steroid
2.1-2.5 luka bakar berat
• Total daily expenditure [TDE] penderita dpt dihitung
dg mengalikan BEE dg aktifitas faktor [AF] dan
injury faktor [IF]
 (MEDICAL NUTRITION THERAPY
FOR HIV-AIDS DISEASE)

• Individual with HIV :

- Decreased oral intake
- GI affected  malabsorption
- Protein,Energy , lipid metabolism ↑↑↑
 lean body wasting
Gastrointestinal and
Pancreatic issues
• The gastrointestinal tract and the pancreas may
also be affected. M. avium complex, greatly
decreased in incidence since the use of powerful
HIV medications, can be seen in the lymph nodes,
liver, bone marrow; blood, and urine of patients
with AIDS. Chronic diarrhea may persist in the
absence of identifiable enteric pathogens as a
result of what is known as AIDS enteropathy.
• Persons with HIV enteropathy may have villous
atrophy and abnormal results on tests of small
bowel function. Because of the vulnerability of
persons with immune suppression to food borne
and waterborne pathogens, food and water safety
is a concern.
 Lipodystropahy and Metabolic
abnormalities

• The use of HIV medications often results in a

generalized lipodystrophy (abnormalities in
fat metabolism with body shape changes and
glucose dysregulation and dyslipidemia),
bone disorders, mitochondrial toxicity, and
lactatemia.
• Morphologic changes include lipoatrophy
(loss of subcutaneous adipose tissue),
resulting in thinning of the arms and legs,
buttocks, and face (maxillary, nasolabial, and
temporal areas).
• The nucleoside reverse transcriptases inhibitors
stavudine and zidor,rrdine have been implicated in the
cause of lipoatrophy, and patients have been delayed
from starting or switched from ART containing those
drugs. Other morphologic changes include accumulation
of visceral adipose tissue, mammary adipose tissue, and
adipose tissue in axillary regions; lipomas; and
enlargement of the dorso cervical fat pad
• Prominent veins from loss of subcutaneous fat and in
grown toe nails have also been reported. Peripheral and
central lipoatrophy occur more in HIV-positive than in HV-
negative persons and can be detected by magnetic
resonance imaging (MRI) but not noticed by the individual
for some time (Bacchetti et al., 2005).
• Metabolic alterations include low serum
testosterone concentrations in both women and
men and elevations in serum triglyceride, insulin,
glucose, and blood pressure (Koder, 2005). Resting
energy expenditure (REE) may be increased with
lipodystrophy and insulin resistance (Kosmiski et
al., 2001).
• Insulin resistance has become a major problem
Antiretrovirals, some more than others, have had a
direct effect on insulin resistance (i.e., raising
cholesterol, LDL, and triglyceride Ievels and
lowering HDL level)
• ART treatrnent increases cardiovascular
disease and diabetes. Use of fish oil alone
or taken with fenofibrate sharply
decreasest riglyceride levels (Mascolini,
2006). Diet, exercise, and weight reduction
if needed are fundamental to treatment
of lipid and glucose dysregulation.
• Factors for changes in bone metabolism
may include low body mass, wasting, poor
nutrition, previous corticosteroid use, or
hormonal deficiencies.
• Potent ART seems to further increase new bone
formation and bone destruction, with greater bone
turnover and loss of bone mineral density.
• Early studies suggest that HlV-positive subjecs who
take protease inhibitors for a while and those with
lipodystrophy syndrome may develop bone loss,
osteopenia, and osteoporosis (Duran et al.,2
001;Moyle, 2001).
• Suggestions include improved diet, use of calcium
and vitamin D dietary supplements, exercise, and
use of biphosphonates such as alendronate or
risedronate (Mondy and Tebas, 2003)
The goals of nutrition intervention are
as follows:
• 1. Maintain and expand nutrition knowledge and
sense of empowerment.
• 2. Maintain or restore healthy body weight and
normal morphology.
• 3. Preserve or restore optimal somatic and visceral
protein status.
• 4. Prevent nutrient deficiencies or excesses known
to compromise immune function.
• 5. Treat or minimize HW or medication-related
complications that interfere with either intake or
absorption of nutrients.
• 6. Correct metabolic abnormalities.
• 7. Support adherence to medications to achieve
optimal therapeutic drug levels.
• 8. Prolong and optimize quality of life.
Interventions

• All persons with HIV infection and AIDS need early,

ongoing medical nutrition therapy. It is essential to
educate individuals about the importance of
consuming a well-balanced diet, to provide
adequate food and nutrients for maintenance or
improvement in nutrition status, and to prevent
protein-energy malnutrition and vitamin and mineral
deficiencies.
• Counseling should be individualized, considering
barriers to adequate intake, and supported with
practical written materials. Mapping out one's meal
and medication schedule is part of medical
nutrition therapy and is an important component for
supporting adherence to the drug regimen.
Energy and Protein

• Energy and protein needs vary depending

on the health status of the individual at the
time of HIV infection, the progression of
the disease and the development of
complications that impair nutrient intake
and use.
• Hypermetabolism occurs.
• Energy requirements increase by 13%
(Grunfeld and Feingold, 1992) and protein
requirements by l0% for every degree
Celsius of temperature elevation above
normal.
• Improvements and reversal of HIV wasting
are noted when using 500 kcal above
estimated energy requirements( use4 0 to
50 kcal/kg of current weight) and 1.6 to 1.8
g of protein per kilogram of current weight
(McDermott et al., 2003). NHLS also found
participants had a 9O-kJ/day (21.5 kcal)
increase in REE per 1-log10 copy/ml
increase in HIV RNA and a 339-kJ/day( 81
kcal)higher REE if they were receiving
ART.
• High-protein diets might safely promote
positive nitrogen balance and lean body
mass repletion, but studies to clarify the
ability of a high-protein diet to reverse HIV
malnutrition and body composition
changes are still needed.
• Protein requirements may be estimated at
1 to I.4 g/kg for maintenance and 1.5 to 2
g/kg for repletion. Because of the
increased protein requirements,
• Protein restriction is indicated only in
persons with severe hepatic or renal
disease
Fat
• Fat tolerance varies from person to person.
In individuals with malabsorption or
diarrhea, use of a low-fat diet may aid in
management. Use of the more readily
absorbed medium chain triglyceride (MCT)
oil is considered better than long chain
triglyceride-based supplements for
decreasing stool fat and stool nitrogen
content and in reducing the number of
bowel movements and abdominal
symptoms.
• Fish oil (omega-3 fatty acids), when
given with MCT oil, may improve
immune function because this
combination is less inflammatory
than the usual omega-6 fatty acids.
If triglyceride and cholesterol levels
are increased, following the
guidelines of the National
Cholesterol Education Program is
recommended
Vitamin and Minerals

• Blood or serum micronutrient levels may not reflect

actual status and measurements of the dietary
intake; recorded intake from supplements may be
more helpful in determining the nutritional
condition (Kupka and Fawzi, 2002).
• The need for increased intake of micronutrients has
been suggested, and it is commonly recommended
that patients take a daily multivitamin and mineral
supplement that provides 100% of the
recommended dietary allowances (RDA and a basic
B-complex supplement, and that they receive
nutrition counseling (Woods et a1.,2002).
Fluid and Electrolytes

• Fluid needs in HIV-infected individuals are

similar to those of well individuals and are
calculated to be 30 to 35 ml/kg per day, with
additional amounts to compensate for losses
from diarrhea, nausea and vomiting, night
sweats, and prolonged fever. Replacement of
electrolyte losses (sodium, potassium, and
chloride) in the presence of vomiting and
diarrhea is also recommended.
• PEM  common complication of HIV,
with the folllowing characteristics :
- weight loss, body cell mass depletion,
decreased skinfold thickness and
mid-arm circumference, decreased
binding capacity & hypoalbuminemia
• The general goals of nutrition
intervention in HIV are to
preserve optimal somatic,
visceral protein status , prevent
nutrient deficiencies or excesses
known to compromiser immune
function, minimize nutrition-
related complication that
interfere with either intake or
absorption of nutrients and
enhance the quality of life
• Nutritional assesment :
- Evaluated diet for adequacy of
nutrient
- Anthropometric measurement
- Laboratory value ( albumine,
transferin, retinol binding protein,
transferin, total iron binding capacity
• Nutritional intervention
Nutrients :
Energy
 Depend on the progression of
the disease and development of
complication
 The Harris and Bennedict 
determine BEE
 Energi requirements increase
13% for every degree Celcius above
normal
 A general range for estimated energy
- 2200-2800 Calori (35-40 Cal/gr BW)
Protein
 Estimated for protein as 1 to 1,2
g/kg body weight> Protein may
need to be restricted in patient
who develop renal or liver disease
Fat
 ii mal-absorption as manifest by
diarrhea is suspected, a low fat
with MCT may be useful
Fluid
 Fluid needs are the same as
those of well individuals,except
in the presence of severe
diarrhea, nausea and vomiting
and prolonged fever
Vitamin & mineral
Megadoses of vitamin and mineral
should be avoided.
Zn and antioxidant vitamins (vit A,
vit C, E may be increased
• DIET TYPE :
- Qualitative diet
an eating plan based on the
type of food allowed ( soft,
high fiber, tube feeding )
- Quantitative diet
an eating plan based on the
amount of the food constituent
• AIDS DIET 1
- acute HIV with febris, dysfagia,
dyspneu, diarrhea, coma
- Liquid diet, small portion and
frequent
• AIDS DIET 2: soft diet
• AIDS DIET 3: normal diet
General nutrition and anabolic
support
• Macronutrients
• Anabolic support
• Micronutrients
 Improve body nitrogen, calori
balance during hypermetabolic
states, progressive depletion of
structural protein still continues
DEMAM TIFOID

A. Konvensional
Mulai bubur saring :
- menurunkan beban kerja
usus
- menurunkan perdarahan
- Netralisasi asam lambung
Syarat bubur saring :
- Mudah dicerna, porsi kecil tapi
sering
- Protein cukup
- memenuhi kebutuhan normal
- kurang bumbu yang tajam
• B. Makanan padat, rendah serat
- defekasi  bulk forming
- BB naik
- Jumlah kalori segera
terpenuhi
- dipersiapkan lebih mudah
- meningkatkan selera makan
 diet yang dipakai sekarang
DIET ENERGI TINGGI
PROTEIN TINGGI
• Diet yang mengandung energi dan
protein diatas kebutuhan normal
Tujuan diet :
- Memenuhi kebutuhan energi
dan protein untuk mencegah
kerusakan tubuh
- Menambah BB hingga mencapai BB
normal
Syarat diet ETPT :
- Energi 40-45 kkql/kg BB
- Protein 2-2,5 g/kgBB
- Lemak 10-20% dari kebuthan energi
tot.
- Karbohidrat, vitamin , mineral cukup
Jenis diet :
- Diet ETPT I
- Diet ETPT II
Sistem “SOAP”

A. Subjective data

B. Objective data

C. Assessment

D. Plan
A. Subjective Data
Riwayat penyakit
• Kontra indikasi
• Anthropometrik data
• Ketidakmampuan untuk makan
sendiri
B. Objective Data
Evaluasi hubungan kebiasaan makan
dan cara hidup
• Evaluasi asupan makanan 3 hari
berturut-turut (recall diet)
• Evaluasi kebiasaan makan dan asupan
makan sebelumnya, antropometrik,
laboratorium dan pemeriksaan klinis.
• Interpretasi hasil laboratorium
• Evaluasi kemampuan penderita untuk
dapat menerima dan mengerti intruksi
diit yang diberikan.
C. Assessment
- Evaluasi and interpretasi
subjective dan objective data
- Menentukan masalah gizi utama
D. P l a n
Tindakan diambil berdasarkan data
Subjektif, Objektif, Assessment
- Rekomendasi untuk melakukan
komunikasi dan evaluasi
- Implementasi, monitoring dan
perbaikan rencana asuhan nutrisi
termasuk tujuan objektif untuk
memecahkan masalah gizi
SUMMARY
Specialized nutrient needs of the INFECTION
patient:
• Increased calories to cover energy costs of
hypermetabolic
• High fat diets.
• Adequate protein levels to support anabolism
and the maintenance of lean body mass..
• Supplemental antioxidants to prevent or
attenuate oxidative damage to tissue
Gizi Pada pasien TB

• Umumnya pasien TB kaheksia

(malnutrisi berat)
• Butuh Diet Tinggi Kalori (40-45
kkal/kgBB dan tinggi protein
(mulai 1.5 g/kgBB)
• Supplementasi Zn 20 mg,
Vitamin A dan Vitamin D