临床营养学

HOME第1章 能量 第2章 蛋白质 第3章 碳水化合物 第4章 脂类 第5章 维生素 第6章 矿物质和水 第7章 植物性非营养生物活性物质 第8章 食物与药物的相互作用 第9章 住院病人的营养膳食 第12节 病人的营养评价、医院膳食 第35节 肠内营养、肠外营养病人膳食指南 第10章 食谱的制定 第11章 营养与呼吸系统疾病 第12章 营养与循环系统疾病,第13章 营养与消化道疾病 第13节 反流性食管炎、胃炎、消化性溃疡 第46节 肠结核、炎症性肠病、腹泻与便秘 第14章 营养与肝、胆、胰疾病 第14节 肝炎、脂肪肝、肝硬化、肝性脑病 第56节 胆石病和胆囊炎、营养与胰腺疾病 第15章 营养与肾脏疾病 第16章 营养与糖尿病 第17章 营养与肥胖病 第18章 营养与痛风 第19章 食物、营养与癌症 第20章 营养与烧伤 第21章 创伤和手术病人的营养支持 第22章 营养与儿科疾病 第23章 营养与妇产科疾病 第24章 营养与其他疾病 第1节 原发性骨质疏松症 第2节 营养与口腔疾病 编写/制作人,普通高等教育“十一五”国家级规划教材 全国高等医药院校教材,临床营养学上 篇,主页目录-Home,基本 概念,郝丽萍 孙秀发,主页目录-Home,营养（nutrition）是指人体摄取、消化、吸收、转运和利用食物中营养物质以满足机体生理需要并排除废物的生物学过程。It is a biological process which nutrients and functional compositions in the foods are ingested , digested, absorbed, transported , utilized and the waste materials are excreted.,主页目录-Home,营养学（nutriology）研究膳食、营养与人体健康关系的科学，广义的营养学，还包括社会、经济、文化、生活习惯和膳食心理等多种领域和学科。 It is a science of foods and the nutrients and other substances they contain, and of their actions within the body. A broader definition includes the social, economic, cultural, and psychological implications of food and eating.,主页目录-Home,营养素（nutrients）食物中可给人体提供能量、机体构成成分和组织修复以及有生理调节功能的化学成分。Chemical substances obtained from food and used in the body to provide energy, structural materials, and repair of the bodys tissues; Nutrients may also reduce the risk of some diseases.,主页目录-Home,protein lipids carbohydrate (dietary fiber) minerals vitamin water,macronutrients,micronutrients,植物化学物：phytochemicals 非营养素 植物的次级代谢产物,Classification of Nutrients,主页目录-Home,营养素生理需要量（Nutritional Requirement）是指能保证人体健康，达到应有发育水平并能充分有效地完成各项体力、脑力活动所需要的能量和各种营养素的必需的量。The lowest continuing intake of energy and nutrients that maintain the specified criterion of adequacy (that will maintain the specific biochemical and physiological functions of the body)最低需要量：指仅能维持生理平衡或不致发生营养缺乏病的量。 适宜需要量：指维持人体健康、促进生长发育、保证最高劳动效率的量。,主页目录-Home,营养素推荐摄入量（Recommended Nutrient Intake，RNI），是指通过膳食，满足某一特定性别、年龄及生理状况群体中绝大多数（97%98%）个体需要的能量和各种营养素的量。 Reference Nutrient Intake (RNI): The RNI is the amount of a nutrient that is enough to ensure that the needs of nearly all the group (97.5%) are being met .,主页目录-Home,第一章 能量Energy,郝丽萍 孙秀发,主页目录-Home,单位 1J：一牛顿力把1kg物体移动1m所需要的能量 1 kcal=4.184KJ 1kJ=0.239 kcal 1000 kcal=4.184MJ 1MJ=239 kcal产能营养素 碳水化合物：（1g4kcal）：55%65% 蛋白质：（1g4kcal）：10%15% 脂 肪：（1g9kcal）：20%30% 酒（乙醇）：1g7kcal,主页目录-Home,第一节 人体的热能消耗 Section 1 The body spends energy,（一）基础代谢（60%75%）（二）体力活动(15%30%)（三）食物的特殊动力作用（TEF）(10%),主页目录-Home,(一) Basal Metabolism,1.Definition,The energy needed to maintain life when a body is at complete rest after a 12-hour fast (禁食).,2. Basic energy expenditure, BEE (基础代谢的热能消耗),(1) Basal metabolic rate, BMR (基础代谢率),Definition,The rate of energy used for metabolism under basal condition, usually expressed as kcal per surface of body per hour (or kcal per kilogram body weight per hour),主页目录-Home,3. Calculation of BEE,BEE = BMRbody surface areatimeBMR (refer to the table)body surface area()0.0065body size(cm) 0.0126body weight(kg) 0.1603,1). According to BMR,主页目录-Home,表1-10 人体基础代谢率,引自营养与食品卫生学，第三版，第21页。,主页目录-Home,2). Harris and Benedict formula,4). The method suggested by WHO: refer to the Table,BEE(man)66.4730+13.75bw.(kg)+5.0033bs.(cm) - 6.7550age(y) BEE(woman)65.0955+9.463bw.(kg)+ 1.8496bs.(cm) - 4.6756age(y),Man BEE (per hour) 1.00 kcal/kg.hr body weight (kg)Woman BEE (per hour)0.95 kcal/kg.hr body weight (kg),3). Simple formula ( for adult ),Resting Metabolic Rate, RMR ( 静息代谢率 ) energy expenditure of body under the rest after 4-hour fast. RMR is more than BMR.,主页目录-Home,WHO 建议的计算基础代谢公式,注:W为体重(kg)。摘自Technical Report Series724,Geneva,WHO,1985。,主页目录-Home,表1-12 人体24小时静息代谢参考值(Kcal),摘自Nutrition Science and Application,第二版，第190页,1997。,主页目录-Home,4. The factors affecting BMR,(1) Body surface area: (or lean mass fatty tissue)(2) Gender: male female (3) Age: 2% of decline per 10 years after age 30 5% of decline per 10 years after age 60 (4) Nutrition state: Low energy intake decreases BMR about 10%-20% (5) Physiological status: Pregnancy increases BMR (6) Body temperature: Fever increases BMR (7) High or low air temperature, hormone system activity, nerve and eating too much increase BMR (Adaptive Thermogenesis , 适应性生热作用) (8) Caffeine and tobacco increase BMR,主页目录-Home,(二) Physical Activity,The energy needed during physical activity depends on body lean mass, intensity (强度) and time of activity. The energy is about 15%-30% of total energy use in sedentary(久坐的) people.,主页目录-Home,(三) Specific dynamic action (or Thermic Effect of Food, TEF)食物特殊动力作用或食物热效应,1. Definition,The amount of extra energy used by body during digestion, absorption, metabolism, and storage of energy-yielding nutrients.,2. Energy expenditure,5%-6% of total calorie produced by carbohydrates,carbohydrates,lipids,4%-5% of that,protein,30% of that,mixed food,10% of total energy consumed（消耗）,主页目录-Home,3. The mechanism,Energy storage: ATP and fat ATP: protein 32%-34% carbohydrate and lipids:38%-40% FAT: lipids fat glucose glycogen or fat amino acid protein or fat,主页目录-Home,4.Affecting factors of TEF,(1)protein-rich food is much higher than others(2) large meals show higher values than normal meals(3) TEF decreases with advancing age. (4) Meal frequency.,主页目录-Home,(一) 计算法calculation,三、Estimating energy requirem 能量需要量的确定,能量消耗的计算=BEEPAL（physical activity level）,中国营养学会建议的我国成人活动水平分级(2001年),主页目录-Home,中国1859岁居民能量推荐摄入量估算,摘自葛可佑主编中国营养科学全书，第27页,主页目录-Home,（一）计算法2. Nutritional survey (or Dietary survey) 膳食调查 57天 摄入食物种类数量， 食物成分表或食物成分分析软件,三、Estimating energy requirements 能量需要量的确定,主页目录-Home,(二)测量法measuring energy use by body直接测热法（direct calorimetry）： 测热装置，水温变化间接测热法(indirect calorimetry) （产生CO2量/耗氧量=呼吸商）生活观察法 24h 各种活动及其时间，查日常活动能量消耗表能量平衡法：1kg体重=29MJ（6931 kcal）,三、Estimating energy requirements 能量需要量的确定,体重增加（能量正平衡）日能量消耗量(MJ)= 能量摄入量(MJ)平均体重增加量(kg)29MJ/调查天数(d),体重减少（能量负平衡）日能量消耗量(MJ)= 能量摄入量(MJ)+平均体重减少量(kg)29MJ/调查天数(d),主页目录-Home,Energy Recommended Nutrition Intake, RNI 热能推荐摄入量,中国居民膳食能量推荐摄入量(RNIs),主页目录-Home,（续表）中国居民膳食能量推荐摄入量(RNIs),主页目录-Home,（续表）中国居民膳食能量推荐摄入量(RNIs),注：AI,非乳母喂养应增加20%。,主页目录-Home,（续表）中国居民膳食能量推荐摄入量(RNIs),主页目录-Home,Question,Describe each component of energy expenditure. What factors influence each? How can energy expenditure be estimated?,主页目录-Home,第二章 蛋白质Protein,郝丽萍 孙秀发,主页目录-Home,含量：体重 16%19%更新： 动态平衡，不断更新，每天约3%，肠和骨髓最快。功能： 1.机体构成成分 2.构成各种生理活性物质和重要的生理功能 3.提供热能,人体中蛋白质,主页目录-Home,人体组织的构成成分 Required for building and repair of body tissues 构成各种生理活性物质和重要的生理功能 Enzymes, hormones, and many immune molecules are proteins. Essential body processes such as water balancing, nutrient transport, and muscle contractions require protein to function. 提供热能 Protein is a source of energy。肽、氨基酸特有的生理功能,第一节 蛋白质功能Section 1 Functions of protein,主页目录-Home,The first structure,蛋白质(protein),氨基酸（Amino acid, AA）,非必需AA(nonessential-)：9种 半必需AA（条件必需AA）：2种 （semi-,or conditionally-）必需AA（essentional-）：9种,多肽（poly-）10 AA以上寡肽（oligo-）410 AA以下 3肽（tri-）3AA 2肽（di-）2AA,肽(peptide),主页目录-Home,1. 种类：20种 (1) 必需AA（EAA） (2) 非必需氨基酸（NEAA） (3) 半必需氨基酸 ( semi-EAA or conditional EAA) 半胱酸（Cysteine）蛋氨酸（Methionine） 酪氨酸（Tyrosine）苯丙氨酸（Phenylalanine）2. 必需氨基酸： 人体不能合成或合成速度不能满足机体需要，必需从食物中直接获得的AA。 Amino acids that the body cannot synthesize in amount sufficient to meet physiological needs and has to obtain them from foods.,第二节 氨基酸和必需氨基 Section 2 Amino acid and EAA,主页目录-Home,表 1-1 人体内的氨基酸,*组氨酸为婴儿必需氨基酸，成人需要量可能较少。 摘自Modern Nutrition in Health and Disease,第9版,第14页,1999。,主页目录-Home,氨基酸模式(AA Pattern)和限制氨基酸 (limiting AA),1. 氨基酸模式 (AA Pattern) ： 蛋白质中各种必需氨基酸的构成比例。,主页目录-Home,表1-2 几种食物和人体蛋白质氨基酸模式,数据摘自营养与食品卫生学，第3版，第9页。,主页目录-Home,限制氨基酸 （limiting amino acid）,与人体蛋白质模式比较，食物蛋白质中含量相对较低的必需AA。 The essential amino acid found in the shortest supply relative to the amount needed for protein synthesis in the body. FourAA are mostlikelytobe limiting: Lysine，Methionine，Threonine，Tryptophan .,主页目录-Home,参考蛋白、完全蛋白和蛋白质的互补作用,参 考 蛋 白,用于测定食物蛋白质质量的标准蛋白。 Reference Protein: A standard against which to measure the quality of other proteins.,完 全 蛋 白,必需氨基酸模式与人体蛋白质相对一致，能满足机体蛋白质合成需要的食物蛋白质。 Complete Protein: A dietary protein containing all the essential amino acids in relatively the same amounts that human being required. (including animal protein and soy protein ) Incomplete protein,蛋 白 质 互 补,将两种或两种以上的食物蛋白质混合事用，使不同食物中必需氨基酸以多补少，从而提高膳食蛋白质的营养价值。 Complementary Protein: Two or more proteins whose amino acids assortments complement each other in such a way that the essential amino acids missing from one are supplied by the other.,主页目录-Home,第三节 蛋白质的消化、吸收和代谢,消化和吸收（digestion and absorption）,主页目录-Home,Gastric Juice : 1. Acid denaturation 2. 胃蛋白酶Pepsin- not highly specific but preferential attack on bonds adjacent to aromatic AA and 亮氨酸(leucine). 3.Carboxypeptidase-terminal aromatic or branch-chained; arginine or lysine; neutral-,dietary Protein,Panc- elastase(弹性蛋白酶)- arometic AA reatic trypsin(胰蛋白酶)- NH2- juice chymotrypsine(糜蛋白酶) - lysine, arginine,dipeptide , tripeptide and free AA,absorbed through the mucosal cells of small intestine 肽酶peptidase,through three active free AA transport systems neutral-,basic- and acidic-.,Liver and other organs,主页目录-Home,代谢与氮平衡 (metabolism and nitrogen balance),1.代谢,摄入蛋白质90克,消 化 道,(30%)肌肉,(50%)器官,体液,其它,机体蛋白质,氨基酸池,粪便10g(1.6gN),尿75g(12gN),其它5g(0.8gN),(20%),肠道内源性蛋白质70g,消化、吸收蛋白质150g,图1-1 蛋白质代谢及氮平衡,主页目录-Home,氮平衡（Nitrogen balance）,(1)必要的氮损失（obligatory nitrogen losses） (2) 氮平衡： BI（UFS）,Positive nitrogen balance,N in N out,N in = N out,Nitrogen equillibrium,Negativenitrogen balance,N in N out,主页目录-Home,第四节 食物蛋白质营养学评价,(一)蛋白质含量 (content）,(2)表观消化率（apparent -）:,(二)蛋白质消化率(digestibility),(1)真消化率（true -）,主页目录-Home,(三)蛋白质利用率（utilization）,1.Biological value, BV:生物价,The amount of protein nitrogen that is retained for growth and maintenance,expressed as a percentage of the protein nitrogen that has been digested and absorbed. To determine the actual value of an absorbed protein as it is used by the body.,主页目录-Home,2.Net Protein Utilization,NPU蛋白质净利用率,The amount of protein nitrogen that is retained from a given amount of protein nitrogen eaten. To determine the amino acid composition and digestibility of a test protein.,主页目录-Home,3.Protein Efficiency Ratio, PER: 蛋白质功效比值,A measure of protein quality assessed bydetermining how well a given protein supportsweight gain in growing rats. Used to establish the protein quality for infantformulas and baby foods.,主页目录-Home,4.Amino Acid Score,AAS氨基酸评分,The lowest score is the score of limiting AA which is the AAS of the protein. A method of evaluating protein quality by comparing a test proteins amino acid pattern with that of a reference protein; sometimes called chemical scoring.,主页目录-Home,表1-4 几种食物和不同人群需要的氨基酸评分模式,摘自WTO Technical Report Series 724,第12页,1985年。,主页目录-Home,表1-5 常见几种食物蛋白质质量,摘自“营养与食品卫生学”，第3版，第11页。,主页目录-Home,5.Protein Digestibility corrected AAS, PDCAAS:（经消化率校正的氨基酸评分）,A measure of protein quality assessed bycomparing the amino acid score of a food proteinWith the amino acid requirements of preschool-ageChildren and then correcting for the truedigestibility of the protein; Recommended by the FAO/WHO and used toestablish protein quality of foods for daily valuepercentage on food labels.,主页目录-Home,表1-6 几种食物蛋白质的PDCAAS,摘自Understanding Nutrition, 第7版，第215页，1996年。,主页目录-Home,第五节 蛋白质营养不良、营养状况评价及食物供给,Kwishiorkor: A Ghanaian word meaning “the evil spirit that infects the first child when the second child is born”. The second child suddenly switched from nutrient dense, protein-rich breast milk to a starchy, protein-poor cereal, soon begins to sicken and die.,Marasmus: A severe deprivation of food over a long time (chronic PEM) and therefore is caused by an inadequate energy and protein intake ( and by inadequate essential fatty acids,vitamins, and minerals as well).,主页目录-Home,蛋白质营养不良,Kwashiorkor,Marasmus,主页目录-Home,Marasmus,Kwashiorkor,Infancy(less than 2 yr),older infants and young children(1-3 yr),Develops slowly;chronic PEM,rapid onset; acute PEM,Severe weight loss,some weight loss,Severe muscle wasting, with fat,Some muscle wasting,with retention of some body fat,Growth:60% weight-for-age,growth:60%-80% weight-for-age,主页目录-Home,No detectable edema,edema,No fatty liver,enlarged fatty liver,Anxiety焦急, apathy淡漠,apathy, misery痛苦, irritability易怒, sadness,Good appetite possible,loss of appetite,Hair is sparse,thin and dry; Easily pulled out,hair is dry and brittle; easily pull out; changes color; becomes straight,Skin is dry, thin, and easily wrinkles,skin develops lesion,主页目录-Home,高蛋白质膳食过多的危害problems of excess protein）,Adult Bone Loss (Osteoporosis骨质疏松): Calcium excretion rises as protein intake increases. Recommen-dation of calcium-to-protein is more than 20(mg) to 1(g).,Cancer: population studies suggest a correlation between high intakes of animal protein and some type cancer ( cancer of colon, breast,kidneys, pancreas, and prostate),Gain Weight: Protein-rich foods are often fat-rich foods. Others.,Heart Disease: Foods rich in animal protein tend tobe rich in saturated fats and cholesterol; homocystei（高半胱氨酸）may be an independent risk factor for heart disease.,主页目录-Home,蛋白质营养状况评价Assessment of protein nutrition in human body,Serum albumin: 35-50g/L Serum transferritin: 2.2-4g/L Retinol-binding protein: 26-76mg/L Thyroxine-binding-albumin:280-350mg/L,主页目录-Home,蛋白质供给量和食物来源 （DRIs and Food source）,RNI: 1) 数量 2）质量 (优质蛋白质)Food Source: animal and plant foods. Milk and Soy been,主页目录-Home,中国居民膳食蛋白质的推荐摄入量: RNI与RDA,主页目录-Home,RNI与RDA：续表,主页目录-Home,Question,What is the difference between essential and nonessential amino acids? Explain these terms: protein-sparing effect, amino acid pattern, protein complementary action . How to evaluate the food protein What are the health consequences of ingesting inadequate protein and energy?,主页目录-Home,第三章 碳水化合物 carbohydrate,李 李,主页目录-Home,单糖(monosaccharide) 双糖(disaccharide) 寡糖(oligosaccharide) 多糖(polysaccharide),一、分类Classification,主页目录-Home,（一）单糖 (monosaccharide),1.葡萄糖（Glucose）: D-and L-. A little in the natural foods.2.果糖（ Fructose）: 主要存在于水果和蜂蜜中，人工制造的玉米糖浆中含 40%-90% 。,Glucose,主页目录-Home,3. 半乳糖（Galactose）：以乳糖形式存在于 天然食物中。 It is not usually found free in nature in large quantities, but rather combines with glucose to form lactose.4. 其他单糖和糖醇: 单糖核糖(ribose)，脱氧核糖( deoxyribose)、阿拉伯糖(arabinose)、木糖(xylose)、糖醇( sugar alcohols) 山梨醇 （ sorbitol ） 、 甘露醇 （ mannitol ） 、 卫矛醇（ dulcitol ） 、 肌醇 （ inositol ）,主页目录-Home,(二)双糖（disaccharide）,1.蔗糖(Sucrose)：葡萄糖果糖，found in sugar cane（甘蔗）and sugar beets（甜菜） 2.麦芽糖（ Maltose）：葡萄糖葡萄糖 3.乳糖（ Lactose）：葡萄糖半乳糖4.海藻糖(Trehalose)：葡萄糖葡萄糖,主页目录-Home,(三)寡糖（oligosaccharide）：3-10单糖组成。寡糖可被肠道益生菌所利用，其发酵产物如短链脂肪酸有重要生理功能，与膳食纤维一道对肠道的结构与功能有重要的保护和促进作用 .,棉籽糖(raffinose)、水苏糖(stachyose)异麦芽低聚糖(isomaltooligosaccharid)低聚果糖（fructooligosaccharide）大豆低聚糖(soybean oligosaccharide),主页目录-Home,(四)多糖（polysaccharide）,1.淀粉（starch）：（1）可吸收淀粉 直链淀粉(amylose)-老化 支链淀粉(amylopectin)-糊化（2）抗性淀粉（resistant starch, RS）,主页目录-Home,2. 膳食纤维（Diet fiber） 包括纤维素、半纤维素和木质素、果胶、树胶等。膳食纤维中的葡萄糖分子是以-键连接，人体淀粉酶不能破坏这种化学键，无法对其进行消化，但它具有重要的营养学意义。,definition:,Nonstarter polysaccharides in plant foods that are not digested by human digestive enzymes, but some are digested by GI tract bacteria. Fiber in foods is also called dietary fiber.,主页目录-Home,纤维素（ Cellulose）: 纤维素是细胞壁的主要成分 半纤维素（ Hemicellulose ） : 半纤维素由许多戊糖和己糖聚合而成的杂多糖。谷类中的可溶的半纤维素被称为戊聚糖木质素（Lignin ）： 木质素是酚核结构物质的高分子聚合物，不能被人体消化吸收。主要存在于蔬菜的木质化部分和种籽中,lignin,cellulose,不溶性膳食纤维（Insoluble fiber）,主页目录-Home,果胶（Pectins）： 果胶是由D-半乳糖醛酸聚合成的复合多糖。柑橘、苹果中含量丰富。食品加工中常用果胶作为增稠剂生产为果冻、色拉、冰淇淋和果酱等。树胶和粘胶（Gums and mucilages）： 树胶和粘胶由不同的单糖及其衍生物组成。如阿拉伯胶(arabic gum are used as additives by the food industry)，瓜拉胶（ guar gum are added to food as stabilizers）,可溶性膳食纤维（soluble fiber ）,主页目录-Home,1. Function of carbohydrate in body,(1)储存和提供能量 （Storing glucose as glycogen and using it for energy）(2)细胞和组织的成分（Component of cells and tissues） : glycoprotein（糖蛋白） and glycolipid（糖脂）,mucin （粘蛋白）, and DNA , RNA. (3)节约蛋白质作用(Sparring protein from use as energy source )：当补充足够碳水化合物则可防止体内和膳食中的蛋白质作为能源，起到节约蛋白质的作用。,二、碳水化合物的功能 Function,主页目录-Home,(4) 抗生酮作用(antiketogenesis),脂肪氧化时需要葡萄糖帮忙，当糖不足时，脂肪酸分解产生的酮体在体内蓄积，以至于产生酮血症和酮尿症。膳食中充足的碳水化合物可以防止上述现象的发生。 enough carbohydrate is necessary for the complete metabolism of fats in the body.,主页目录-Home,(1) 供能（Supplying energy ） Carbohydrate is the cheapest and broadest food energy source in the world (4kcal/g). (2)改变食物的色、香、味、形(Impartingcolor, flavor to foods and changing their shape)利用碳水化合物的各种性质，加工各种色、香、味、形的食品 (3) 提供膳食纤维（Supplying dietary fiber）,2. Function of carbohydrate in foods,Function of dietary fiber,Weight control；Lowing serum cholesterol；Making elimination of feces much easier； playing a key role in preventing colon cancer of the large intestine,主页目录-Home,1. 消化过程 ( the processes of digestion)(1)在口腔(in the mouth):食物进入口腔后，唾液中淀粉酶使淀粉分解，产生少量的糊精、麦芽糖及葡萄糖(2)在胃(in the stomach):淀粉一般在胃中不被消化 (3)在小肠(in