Study Guide Clinical Nutrition & disorders

CORE CURRICULUM

Clinical Nutrition and Disorder

Aims

Capable to explain the concept of human nutrition and set the comprehensive action for nutritional problems, in health and disease in the primary care settings.

Learning outcomes

  1. Explain the roles of macronutrients and micronutrients in health and diseases, and its food sources
  2. Estimate the general nutritional and energy requirements in relation to age, sex, activity, stress, pregnancy and nursing mother.
  3. Explain the general principles of well-balanced diet
  4. Assess the nutritional status in health and diseases, includedetermining nutritional deficiency and excess
  5. Determine the difference of concepts among vitamin deficiency, dependency and toxicity
  6. Identify mineral deficiency and toxicity
  7. Explain the nutrition concepts, specialties and burdens through the life cycle
  8. Explain the nutrition concepts for obesity and weight management, dislipidaemia and hyperurecemia
  9. Explain the concept of medical nutrition therapy in primary care setting
  10. Explain the concept of food supplement and functional food in primary care setting
  11. Diagnose and manage common problems and diseases of micronutrient defiecienciesin the primary care settings.
  12. Explain the basic concepts and principles of enteral and parenteral (IntraVenous) nutrition.

Curriculum content

1.Role and food sourcesof nutrients

2.Need of general nutritional and energy requirements in specific physiological conditions

3.Macro and micronutrients

4.The concept of well-balanced diet and it’s implementation

5.Assessment of general nutritional status that has been used in community as well as in
clinical setting

6.Management of common nutritional problems :

6.1 Malnutrition (Undernutrition)

6.2 Obesity

6.3 Weight management

6.4 Infant Feeding Practice

6.5 Dislipidaemia

6.6 Hyperurecemia

7.The principles of medical nutritional therapy (MNT)

8.The principles of enteral and parenteral nutrition

9.Food Supplement and Functional Food

~ PLANNERS TEAM ~

No / Name / Departement / Phone
1 / Dr. dr. Gde Ngr Indraguna Pinatih, M.Sc, Sp.GK / Community & Preventive Medicines / 08123816424
2 / Dr. dr. I Wayan Suranadi, Sp.An-KIC / Anesthetic Reanimation / 08123847675
3 / Dr. dr. I Gst Lanang Sidiarta, Sp.A(K) / Pediatrics / 08123966008
4 / Dr. dr. I Wayan Weta, MS, Sp.GK / Community & Preventive Medicines / 081337005360
5 / dr. I Wayan Gede Sutadarma, M.Gizi,Sp.GK / Biochemistry / 082144071268

~ LECTURERS ~

NO / NAME / DEPT / PHONE
1 / Dr. dr. I Wayan Suranadi, Sp.An-KIC (WSR) / Anesthtic and Reanimation / 08123847675
2 / Dr.dr. Putu Pramana, Sp.An-KMN (PRM) / Anesthetic and Reanimation / 08122344895/03617405330
3 / Dr.dr. I Wayan Weta, MS, Sp.GK (WT) / Community and Preventive Medicines / 081337005360
4 / Dr.dr. Gde Ngr Indraguna Pinatih, M.Sc, Sp.GK (GNIP) / Community and Preventive Medicines / 08123816424
5 / Dr.dr. IGst Lanang Sidiarta, SpA.(K) (IGLS) / Pediatrics / 08123966008
6 / dr. I Wayan Gede Sutadarma, M.Gizi,Sp.GK (SUT) / Biochemistry / 082144071268

~ FACILITATORS ~

Regular Class

NO / NAME / GROUP / DEPT / PHONE / ROOM
1 / dr. I Putu Kurniyanta, Sp.An / A1 / Anasthesi / 081805755222 / 3rd floor R.3.01
2 / dr. Tjok. Istri Anom Saturti, Sp.PD / A2 / Interna / 081916253777 / 3rd floor R.3.02
3 / dr. Herman Saputra, Sp.PA / A3 / Pathology Anatomy / 081338981853 / 3rd floor R.3.03
4 / dr. Yuliana, M Biomed / A4 / Anatomy / 085792652363 / 3rd floor R.3.04
5 / dr. I.B. Krisna Jaya Sutawan, Sp.An, M.Kes / A5 / Anasthesi / 08123836470 / 3rd floor R.3.05
6 / dr. Ida Ayu Sri Wijayanti, M.Biomed, Sp.S / A6 / Neurology / 081337667939 / 3rd floor R.3.06
7 / Dr.dr. I G A Sri Mahendra Dewi, Sp.PA(K) / A7 / Pathology Anatomy / 081338736481 / 3rd floor R.3.07
8 / dr. Ryan Saktika Mulyana, M.Biomed, Sp.OG / A8 / Obgyn / 082147087905 / 3rd floor R.3.08
9 / dr.A.A. Ayu Dwi Adelia Yasmin, M.Biomed, Sp.JP,FIHA / A9 / Cardiology / 087861402169 / 3rd floor R.3.20
10 / dr. I Made Dwijaputra Ayustha, Sp.Rad / A10 / Radiology / 08123670195 / 3rd floor R.3.21
11 / dr. I Made Oka Adnyana, Sp.S (K) / A11 / Neurology / 0817347697 / 3rd floor R.3.22
12 / dr. I Gusti Agung Gd Mahendra Wijaya, Sp.Onk,. Rad / A12 / Radiology / 08990179750 / 3rd floor R.3.23

English Class

NO / NAME / GROUP / DEPT / PHONE / ROOM
1 / dr. I Gede Ketut Sajinadiyasa, Sp.PD / B1 / Interna / 085237068670 / 3rd floor R.3.01
2 / dr. Kadek Agus Heryana, Sp.An / B2 / Anasthesi / 081338568883 / 3rd floor R.3.02
3 / dr. Made Agus Hendrayana , M.Ked / B3 / Microbiology / 08123921590 / 3rd floor R.3.03
4 / dr. Ni Putu Ekawati, M.Repro, Sp.PA / B4 / Pathology Anatomy / 08113803933 / 3rd floor R.3.04
5 / dr. Firman Parulian Sitanggang, Sp.Rad(K)RI / B5 / Radiology / 081337165566 / 3rd floor R.3.05
6 / dr. Ketut Suardamana, Sp.PD-KAI / B6 / Interna / 08123985811 / 3rd floor R.3.06
7 / dr. I Made Oka Negara, S.Ked / B7 / Andrology / 08123979397 / 3rd floor R.3.07
8 / Dr.dr. I Made Muliarta, M.Kes / B8 / Physiology / 081338505350 / 3rd floor R.3.08
9 / Dr.dr. Dyah Pradnyaparamita Duarsa, M.Si / B9 / Public Health / 0818357777 / 3rd floor R.3.20
10 / Prof. dr. Nyoman Agus Bagiada, Sp.Biok / A10 / Biochemistry / 081338338611 / 3rd floor R.3.21
11 / dr. Anak Agung Mas Putrawati Triningrat, Sp.M (K) / A11 / Opthalmology / 08123846995 / 3rd floor R.3.22
12 / dr. Lely Setyawati , Sp.KJ / B12 / Psychiatry / 08174709797 / 3rd floor R.3.23

TIME TABLE

Days/date / Time / Learning Activity / Place / PIC
Regular Class / English Class
1st day
Tuesday
1 Dec2015 / 08.00-09.00 / 09.00-10.00 /

Introduction of theTheme

/ Class room / GNIP
09.00-10.30 / 12.00-13.30 / Independent Learning
10.30-12.00 / 13.30-15.00 / SGD / Discussion room
12.00-12.30 / 11.30-12.00 / Break
12.30-13.30 / 15.00-16.00 / Plenary
13.30-15.00 / 10.00-11.30 /

Student project

2nd Day
Thursday
3 Dec 2015 / 08.00-09.00 / 09.00-10.00 /

Nutrition and Life Cycle

/ Class room / WSR
09.00-10.30 / 12.00-13.30 / Independen Learning
10.30-12.00 / 13.30-15.00 / SGD / Discussion room
12.00-12.30 / 11.30-12.00 / Break
12.30-13.30 / 15.00-16.00 /

Plenary

/ Class room
13.30-15.00 / 10.00-11.30 /

Student project

3rd Day
Friday
4 Dec 2015 / 08.00-09.00 / 09.00-10.00 /

Well Balance Diet

/ Class room / GNIP
09.00-10.30 / 12.00-13.30 / Independen Learning
10.30-12.00 / 13.30-15.00 / SGD / Discussion room
12.00-12.30 / 11.30-12.00 / Break
12.30-13.30 / 15.00-16.00 /

Plenary

/ Class room
13.30-15.00 / 10.00-11.30 /

Student project

4th Day
Monday
7 Dec 2015 / 08.00-09.00 / 09.00-10.00 /

Infant and Children Feeding Practice

/ Class room / IGLS
09.00-10.30 / 12.00-13.30 / Independent Learning
10.30-12.00 / 13.30-15.00 / SGD / Discussion room
12.00-12.30 / 11.30-12.00 / Break
12.30-13.30 / 15.00-16.00 / Plenary / Class room
13.30-15.00 / 10.00-11.30 /

Student project

5th Day
Tuesday
8 Dec 2015 / 08.00-09.00 / 09.00-10.00 / Obesity and Weight Management / Class room / GNIP
09.00-10.30 / 12.00-13.30 / Independent Learning
10.30-12.00 / 13.30-15.00 / SGD / Discussion room
12.00-12.30 / 11.30-12.00 / Break
12.30-13.30 / 15.00-16.00 / Plenary
13.30-15.00 / 10.00-11.30 /

Student project

/ Class room
6th Day
Thursday
10 Dec 2015 / 08.00-09.00 / 09.00-10.00 /

Primary Protein and Energy Malnutrition

/ Class room / WT
09.00-10.30 / 12.00-13.30 / Independent Learning
10.30-12.00 / 13.30-15.00 / SGD / Discussion room
12.00-12.30 / 11.30-12.00 / Break
12.30-13.30 / 15.00-16.00 / Plenary / Class room
13.30-15.00 / 10.00-11.30 /

Student project

7th day
Friday
11 Dec 2015 / 08.00-09.00 / 09.00-10.00 / Secondary Protein and Energy Malnutrition / Classroom / WT
09.00-10.30 / 12.00-13.30 / Independent Learning
10.30-12.00 / 13.30-15.00 / SGD / Discussion room
12.00-12.30 / 11.30-12.00 / Break
12.30-13.30 / 15.00-16.00 / Plenary / Classroom
13.30-15.00 / 10.00-11.30 /

Student project

8th day
Monday
14 Dec 2015 / 08.00-09.00 / 09.00-10.00 / Minerals Deficiency / Class room / SUT
09.00-10.30 / 12.00-13.30 / Independent Learning
10.30-12.00 / 13.30-15.00 / SGD / Discussion room
12.00-12.30 / 11.30-12.00 / Break
12.30-13.30 / 15.00-16.00 / Plenary / Class room
13.30-15.00 / 10.00-11.30 /

Student project

9th day
Tuesday
15 Dec 2015 / 08.00-09.00 / 09.00-10.00 / Vitamins Deficiency / Class room / GNIP
09.00-10.30 / 12.00-13.30 / Independent Learning
10.30-12.00 / 13.30-15.00 / SGD / Discussion room
12.00-12.30 / 11.30-12.00 / Break
12.30-13.30 / 15.00-16.00 / Plenary / Class room
13.30-15.00 / 10.00-11.30 /

Student project

10th day
Wednesday
16 Dec 2015 / 08.00-09.00 / 09.00-10.00 / Nutrition Management for Dyslipidemia and Hyperuricemia / Class room / WT
09.00-10.30 / 12.00-13.30 / Independent Learning
10.30-12.00 / 13.30-15.00 / SGD / Discussion room
12.00-12.30 / 11.30-12.00 / Break
12.30-13.30 / 15.00-16.00 / Plenary / Class room
13.30-15.00 / 10.00-11.30 /

Student project

11th day
Thursday
17Dec2015 / 08.00-09.00 / 09.00-10.00 /

Food Supplement (Functional Food and Antioxidant)

/ Class room / SUT
09.00-10.30 / 12.00-13.30 / Independent Learning
10.30-12.00 / 13.30-15.00 / SGD / Discussion room
12.00-12.30 / 11.30-12.00 / Break
12.30-13.30 / 15.00-16.00 / Plenary / Class room
13.30-15.00 / 10.00-11.30 /

Student project

12th day
Friday
18 Dec2015 / 08.00-09.00 / 09.00-10.00 / Enteral and Parenteral Nutrition / Classroom / WSR/PRM
09.00-10.30 / 12.00-13.30 / Independent Learning
10.30-12.00 / 13.30-15.00 / SGD / Discussion room
12.00-12.30 / 11.30-12.00 / Break
12.30-13.30 / 15.00-16.00 / Plenary / Classroom
13.30-15.00 / 10.00-11.30 /

Student project

13th day
Monday
21Dec2015 / 08.00-09.00 / 09.00-10.00 / Medical Nutritional Therapy / Classroom / SUT
09.00-10.30 / 12.00-13.30 / Independent Learning
10.30-12.00 / 13.30-15.00 / SGD / Discussion room
12.00-12.30 / 11.30-12.00 / Break
12.30-13.30 / 15.00-16.00 / Plenary / Classroom
13.30-15.00 / 10.00-11.30 /

Student project

14th day
Tuesday
22 Dec 2015 / 08.00-14.00 / 08.00-14.00 / BCS
Nutr assessment Screening/Food planning/Food planning / Skill Lab Classroom / TEAM
15th day
Wednesday
23 Dec2015 / 08.00-14.00 / 08.00-14.00 / BCS
Nutr assessment Screening / Skill Lab Classroom / TEAM
15th day
Monday
28 Dec 2015 / 08.00-14.00 / 08.00-14.00 /

Student Project

/ Discussion room
15th day
Tuesday
29 Dec 2015 / 08.00-14.00 /

Final Examinatiom

/ Class room / TEAM

STUDENT PROJECT

The aim of the student project in this block is to provide the opportunity for the student to learn more deeply on recent vitamin and mineral deficiency issues. In the mild situation these kind of problem usually asymptomatic or the symptom appears in different aspect of organ disease, but then it can give serious impact to the person who get it. For example folic acid deficiency in pregnant mother causing neural defect to the offspring. This situation often called as hidden malnutrition accordingly.

Students shall disparted themself in group following the small discusiion group and then for the topic, theymay choose one out of 16 topic of vitamin: A,B,C,D,E,K or minerals macro: Ca and P, Mg, Na, K, Cl or Micro: Fe, Zn, I, Se, Mn. The report shall follow the scientific writing procedure produced by the university of Udayana. The Reference used in the the project shall be the most recent one, may be not older than 2010, except there isn’t any recent literature available to the particular topic.

Fascilitators are requested to fascilitate and examine these project.

REPORT FORMAT

  1. Introduction: background and the evidence of malnutrition in certain topic
  2. Basic knowledge: structure, food resources, need
  3. Digestion and absorption
  4. Metabolism in cell in connection to its spesific function i.e. immunity, sight, growth etc.
  5. Nutritional therapy: how to process and serve it
  6. Referrence

REPORT SHALL BE SUBMITED

WEDNESDAY, 23th. Dec 2015

LEARNING TASK

1st day

INTRODUCTION OF THE THEME

Case 1.

Looking at Indonesian household study on health from 2007-2013 Indonesia has faced two burdens on nutrition over and undernourished which then called malnutrition. In one way we still facing chronic malnutrition shown as stuntet which will create problems on non communicable diseases in the future, in the other way the number of obesity and its related diseases are increasing . Furthermore, concerning health including nutrition we have other burdens those are teens and elderly, as the number of yiung adult as well as old people are also increasing. All theseneed more effort and budget to handle the problems. Poverty and natural disaster lead to increase nutritional problems especialy undernutrition. In other side, increasing wellness on small group of population lead to increase the risk of overnutrition and degenerative diseases. To minimize the risk of nutritional problem, optimal nutrition is needed to be applied in all population groups.

  1. Explain, what does it mean by optimal nutrition, whilst human eating food?
  2. Discuss how optimal nutrition can be apllied within individual as well as community
  3. Explain, what causing people to get malnourished, under or overweight?
  4. Mention stages of nutrition development and how to assess it?
  5. What is the main nutritional problems in Indonesia and what is the arising nutrition problem today and its health risk?

Case 2.

A 5 years old girl, taken by her mother to the clinic (Health Centre). Her mother tells the doctor that she often got sick, it is nearly monthly. Her appetite also told as less. Looking at her growth monitoring chart, her weight falling down since she was1 year. She got breast milk only 3 month because her mother has gone for a work and she is under her grandma cares when her parent is absent for work. She looks shorter to her mostly friend, she is less active for her age and irrtable. When they check her appetite, actually she eats heartlily

Learning Task

  1. What the appropriate information and assessment you should collect to support diagnose of the nutrition problem?
  2. Looking at the sysmtoms above what illness might possible happenned to this girl and does it a reversible disease?
  3. Should you think that it is a reversible disease, what is your advise to reverse her problem?
  4. Beside nutrition factors, what is the others contributing factors might influence these conditions?

2nd day

NUTRITION AND THE LIFE CYCLE

Case

Young mother come to your private clinic with her 6 months old girl infant. She complains that her infant’s weight gain was different with the neighbor’s one. She gives exclusive breastfeeding for her baby and she ask you when she must start to give solid foods?

Learning Task

  1. What is the meaning of exclusive breastfeeding and how long should it be given?
  2. How to start solid foods, when to start solid foods and what kind of foods should be given to start with the solid food in infant feeding practice?

Self-Assessment

  1. Describe some of the nutrient and immunological attributes of breast milk.
  2. Describe criteria would you use in selecting an infant formula.
  3. Describe when an infant is ready to start eating solid food.
  4. List foods that are inappropriate for infants and discuss why they are inappropriate.
  5. List strategies for introducing nutritious foods to children.
  6. Describe changes in nutrient needs from childhood to adolescence.

3rd day

WELL BALANCE DIET

Case 1.

A young athlete 19 years old, height 178 cm, weight 70 kg. wants to maintain his ideal body weight as well as performance. He practice as athelete everyday with vigorous activity in the afternoon. After calculating his energy need, he is dicided to get 3000 kcal perday

Learning Task :

1. Calculate the macronutient (carbohydrate, protein and fat) need following to his energy need and to get balanced diet.

2. Put your calculation into meal frequency include snack

3. Translate into food stuff that shall be given to meet his need

4. Discuss whether he needs special food before, during and after training.

5. Discuss whether he need an extra supplement to add his intake, and what supplement is best to be given to him.

Case 2

A26 years oldwoman, have just married, weight 54 kg, and height 160 cm, come to obstetric clinic to ask for advice on maintaining healthy pregnancy. She is worry of falling into nutritional deficiency when she get and during her pregnancy. Therefore, to prevent it she needs as many as information and adviseson how to keep the optimal fetal growth and optimal nutrition status of pregnantand lactating mother.

Learning task.

  1. Calculate energy requirement of pregnant woment within 1st, 2nd, and 3rd trimester of pregnancy
  2. Translate the total energy requirement of pregnant women in the all trimester into daily foodstuff. Make sure that the composition is appropriate to the requirement of balanced diet
  3. What kind of protein resources is better to be used to get an optimal nutrition in the pregnancy? Explain why is it so
  4. In menu planning, split all foodstuff into three main menu (breakfast, lunch and dinner) and two snack?
  5. To optimize the nutrient availability what kind of foodstuff should be included in the menu?
  6. If any case you find nutrient deficiency in the daily food intake, what suggestion shall be given to preventand reverse it? Give the reason of your particular suggestion!
  7. What shall you do to fill adequately all nutrient intake, both the quality and the quantity ?
  8. For maintaining optimal infant growth and healthy mother, what kind of food are selected to the mother?
  9. List and explain the steps that have to be done before planning a meal
  10. To facilitate you to plan an adequate diet, you need some tools such as RDA (Recommended Daily Allowance), and Food Exchange List. Describe the adventage and disadvantage of both these two tools

4th day

INFANT AND CHILDREN FEEDING PRACTICE

Case

Young mother come to your private clinic with her 6 months old girl infant. She complains that her infant’s weight gain was different with the neighbor’s one. She gives exclusive breastfeeding for her baby and she ask you went she must start to give solid foods?

Learning Task

  1. What is the meaning of exclusive breastfeeding and how long should be given?
  2. How to start solid foods, when to start solid foods and what kind of foods were given at the first time?

Self-Assessment

  1. Describe some of the nutrient and immunological attributes of breast milk.
  2. Describe criteria would you use in selecting an infant formula.
  3. Describe when an infant is ready to start eating solid food.
  4. List foods that are inappropriate for infants and discuss why they are inappropriate.
  5. List strategies for introducing nutritious foods to children.

5th day

OBESITY AND WEIGHT MANAGEMENT

Case 1.

Suharni, 27 years old, has got her gained weight since 4 years ago when she delivered her baby. Before pregnant her weight was 55 kg while her heigt was 160 cm. When she was pregnant, her weight increase 16 kg, and now her weight is 80 kg. She wants to have baby and she has been trying to do it unsuccesfully since one year ago. The obstetricus suggest her to reduce her weight, before trying it again.

Learning task:

  1. Count Suharni’s Body Mas Index before and after she gain weight and her nutrition status base on her BMI.
  2. Discuss what is happening on her untill she gain her weight that much
  3. What measurement need to be added to diagnose such condition above
  4. Discuss the laboratory tested need to be carried out to distinguish whether she got the comorbidity or not
  5. Theoritically what is the cause for obesity
  6. Should She has to reduce her weight what she need to do.

6th day

PRIMARY PROTEINandENERGY MALNUTRITION

Case 1.

A 28 years old man, height 178 cm, and 24 years old woman, height 164 cm, want to maintain their ideal body weight.Both of them are in moderate activity.

Learning task

  1. For the two people, calculate the Ideal Body Weight, energy requirement, energy intake to meet energy balanced

Note:

Total energy output is the summary of your’s body three uses of energy:

a)Resting metabolic rate (RMR)

b)Thermic effect of food (TEF)

c)Physical activity

a)RMR (use general formula) :

Women : 0.9 kcalories/kg bb/hr

Men : 1.0 kcalories/kg bb/hr

b)TEF : 10% of total energy intake

c)Physical activity

Average activity level / Energy cost (% or RMR)
Sedentary / 20
Very light / 30
Moderate / 40
Heav / 50

d)Calculate Total energy output :

Total energy output (kcal)= …..(RMR) + ….(TEF) + …..(Physical activity).

2. Calculate the Carbohydrate, Protein and fat composition to get a healthy diet.

Case 2.

In a party, there will be many kinds of food will be served. Mostly of those foods will comprise of animal base food such as pork, beef and or fish and cooked in several kind of menu

Learning task.

  1. If someone always eat a big portion of meet but less fish, what kind of fatty acid will be eaten more? What is the type of fatty acid will be in the pork and the beef?
  2. What is the impact of such fatty acid to the health if daily menu consist of mostly fatty meat?
  3. What kind of fatty acid are composed in the fish?
  4. If some one eats fish more frequent, what is the beneficial effect of fish fat to the health? Explain your reason!
  5. Compare saturated, monounsaturated, and polyunsaturated fatty acids in term of their : a) chemical composistion, b) effect on health, c) usuall food sourches.
  6. Describe the meaning of P:S ratio of fatty acid and the ideal composition
  7. Name the essential fatty acids. Why they are called essential? What will happen if the essential fatty acids are in a short supply? What suggestion should be given in this situation?
  8. Differentiate the clinical benefit of essential fatty acid between omega-3 and 6
  9. What are the potential problems associated with excess amount of eating fat in generall?

Case 3.