Basal Metabolic Rate (BMR), and the closely related resting metabolic rate (RMR), is the amount of daily

energy expended by humans and other animals at rest. Rest is defined as existing in a neutrally temperate environment while in the post-absorptive state. The release, and using, of energy in this state is sufficient only for the functioning of the vital organs, the heart, lungs, nervous system, kidneys, liver, intestine, sex organs, muscles, and skin. The body's generation of heat is known as thermogenesis and it can be measured to determine the amount of energy expended. BMR decreases with age generally (as people usually don't maintain lean body mass) and with the loss of lean body mass. Increasing muscle mass increases BMR. Aerobic fitness level, a product of cardiovascular exercise, while previously thought to have effect on BMR, has been shown in the 1990s not to correlate with BMR.New research has however come to light which suggests anaerobic exercise does increase resting energy consumption. Indirect calorimetry laboratory with canopy hood (dilution technique)BMR is measured under very restrictive circumstances when a person is awake. An accurate BMR measurement requires that the person's sympathetic nervous system not be stimulated, a condition which requires complete rest. A more common and closely related measurement, used under less strict conditions, is resting metabolic rate (RMR) BMR and RMR are measured by gas analysis through either direct or indirect calorimetry, though a rough estimation can be acquired through an equation using age, sex, height, and weight. Studies of energy metabolism using both methods provide convincing evidence for the validity of the respiratory quotient (R.Q.), which measures the inherent composition and utilization of carbohydrates, fats and proteins as they are converted to energy substrate units that can be used by the body as energy. Studies conducted by Spennewyn in 1990 found strong correlations between lean mass and metabolism based on indirect calorimetry measurements. Spennewyn discovered that lean tissue in men and women required approximately 16 calories per pound per day. Thus, once a lean mass was known it could be multiplied by 16 to reveal daily caloric needs based on the activity level of the individual. This method has been used to determine daily caloric needs.

Anaerobic exercise Anaerobic exercise is exercise intense enough to trigger anaerobic metabolism. It is used by athletes in nonendurance sports to promote strength, speed and power and by body builders to build muscle mass. Muscle energy systems trained using anaerobic exercise develop differently compared to aerobic exercise, leading to greater performance in short duration, high intensity activities, which last from mere seconds up to about 2 minutes. Any activity after about two minutes will have a large aerobic metabolic component. Anaerobic metabolism, or anaerobic energy expenditure, is a natural part of whole-body metabolic energy expenditure. Fast twitch skeletal muscle (as compared to slow twitch muscle) operates using anaerobic metabolic systems, such that any recruitment of fast twitch muscle fibers will lead to increased anaerobic energy expenditure. Intense exercise lasting upwards of about four minutes (e.g., a mile race) may still have a considerable anaerobic energy expenditure component. Anaerobic energy expenditure is difficult to accurately quantify, In sports which require repeated short bursts of exercise however, it is the anaerobic system that enables muscles to recover for the next burst. Therefore training for many sports demands that both energy producing systems be developed. There are two types of anaerobic energy systems: 1) the high energy phosphates, ATP adenosine triphosphate and CP creatine phosphate and, 2) anaerobic glycolysis. The high energy phosphates are stored in very limited quantities within muscle cells. Anaerobic glycolysis exclusively uses glucose (and glycogen) as a fuel in the absence of oxygen or

more specifically, when ATP is needed at rates that exceed those provided by aerobic metabolism; the consequence of rapid glucose breakdown is the formation of lactic acid (more appropriately, lactate at biological pH levels). Physical activities that last up to about thirty seconds rely primarily on the former, ATP-PC phosphagen, system. Beyond this time both aerobic and anaerobic glycolytic metabolic systems begin to predominate. The by-product of anaerobic glycolysis, lactate, has traditionally thought to be detrimental to muscle function. However, this appears likely only when lactate levels are very high. In reality, many changes occur within and around muscle cells during intense exercise that can lead to fatigue, with elevated lactate levels being only one (fatigue, that is muscular failure, is a complex subject). Elevated muscle and blood lactate concentrations are a natural consequence of physical exertion, regardless of what form it takes: easy, moderate, hard or severe. The effectiveness of anaerobic activity can be improved through training. Aerobic exercise and fitness can be contrasted with anaerobic exercise, of which strength training and shortdistance running are the most salient examples. The two types of exercise differ by the duration and intensity of muscular contractions involved, as well as by how energy is generated within the muscle. In most conditions, anaerobic exercise occurs simultaneously with aerobic exercises because the less efficient anaerobic metabolism must supplement the aerobic system due to energy demands that exceed the aerobic system's capacity. What is generally called aerobic exercise might be better termed "solely aerobic", because it is designed to be low-intensity enough not to generate lactate via pyruvate fermentation, so that all carbohydrate is aerobically turned into energy. Initially during increased exertion, muscle glycogen is broken down to produce glucose, which undergoes glycolysis producing pyruvate which then reacts with oxygen (Krebs cycle) to produce carbon dioxide and water and releasing energy. If there is a shortage of oxygen (anaerobic exercise, explosive movements), carbohydrate is consumed more rapidly because the pyruvate ferments into lactate. As carbohydrates deplete, fat metabolism is increased so that it can fuel the aerobic pathways. The latter is a slow process, and is accompanied by a decline in performance level. This gradual switch to fat as fuel is a major cause of what marathon runners call "hitting the wall". Anaerobic exercise, in contrast, refers to the initial phase of exercise, or to any short burst of intense exertion, in which the glycogen or sugar is respired without oxygen, and is a far less efficient process. Operating anaerobically, an untrained 400 meter sprinter may "hit the wall" short of the full distance. Aerobic exercise Aerobic exercise comprises innumerable forms. In general, it is performed at a moderate level of intensity over a relatively long period of time. For example, running a long distance at a moderate pace is an aerobic exercise, but sprinting is not. Playing singles tennis, with near-continuous motion, is generally considered aerobic activity.Some sports are thus inherently "aerobic", while other aerobic exercises, such as fartlek training or aerobic dance classes, are designed specifically to improve aerobic capacity and fitness. Among the recognized benefits of doing regular aerobic exercise are: y Strengthening the muscles involved in respiration, to facilitate the flow of air in and out of the lungs y Strengthening and enlarging the heart muscle, to improve its pumping efficiency and reduce the resting heart rate, known as aerobic conditioning y Strengthening muscles throughout the body y Improving circulation efficiency and reducing blood pressure y Increasing the total number of red blood cells in the body, facilitating transport of oxygen y Improved mental health, including reducing stress and lowering the incidence of depression y Reducing the risk for diabetes. y Burns body fat, while building leaner muscle. As a result, aerobic exercise can reduce the risk of death due to cardiovascular problems. In addition, high-impact aerobic activities (such as jogging or using a skipping rope) can stimulate bone growth, as well as reduce the risk of osteoporosis for both men and women. In addition to the health benefits of aerobic exercise, there are numerous performance benefits: y Increased storage of energy molecules such as fats and carbohydrates within the muscles, allowing for increased endurance y Neovascularization of the muscle sarcomeres to increase blood flow through the muscles y Increasing speed at which aerobic metabolism is activated within muscles, allowing a greater portion of energy for intense exercise to be generated aerobically y Improving the ability of muscles to use fats during exercise, preserving intramuscular glycogen y Enhancing the speed at which muscles recover from high intensity exercise y Both the health benefits and the performance benefits, or "training effect", require a minimum duration and frequency of exercise. Most authorities suggest at least twenty minutes performed at least three times per week. BiochemistryEnergy expenditure breakdown Liver 27% Brain 19% Heart 7% Kidneys 10% Skeletal muscle 18% Other organs 19% About 70% of a human's total energy expenditure is due to the basal life processes within the organs of the body (see table). About 20% of one's energy expenditure comes from physical activity and another 10% from thermogenesis, or

digestion of food (postprandial thermogenesis). All of these processes require an intake of oxygen along with coenzymes to provide energy for survival (usually from macronutrients like carbohydrates, fats, and proteins) and expel carbon dioxide, due to processing by the Krebs cycle. For the BMR, most of the energy is consumed in maintaining fluid levels in tissues through osmosis, and only about one-tenth is consumed for mechanical work, such as digestion, heartbeat, and breathing. What enables the Krebs cycle to perform metabolic changes to fats, carbohydrates, and proteins is energy, which can be defined as the ability or capacity to do work. The breakdown of large molecules into smaller molecules associated with release of energy is catabolism. The building up process is termed anabolism. The breakdown of proteins into amino acids is an example of catabolism, while the formation of proteins from amino acids is an anabolic process. Exergonic reactions are energy-releasing reactions and are generally catabolic. Endergonic reactions require energy and include anabolic reactions and the contraction of muscle. Metabolism is the total of all catabolic, exergonic, anabolic, endergonic reactions. Adenosine Triphosphate (ATP) is the intermediate molecule that drives the exergonic transfer of energy to switch to endergonic anabolic reactions used in muscle contraction. This is what causes muscles to work which can require a breakdown, and also to build in the rest period, which occurs during the strengthening phase associated with muscular contraction. ATP is composed of adenine, a nitrogen containing base, ribose, a five carbon sugar (collectively called adenosine), and three phosphate groups. ATP is a high energy molecule because it stores large amounts of energy in the chemical bonds of the two terminal phosphate groups. The breaking of these chemical bonds in the Krebs Cycle provides the energy needed for muscular contraction.

Glucose
Because the ratio of hydrogen to oxygen atoms in all carbohydrates is always the same as that in water that is, 2 to 1 all of the oxygen consumed by the cells is used to oxidize the carbon in the carbohydrate molecule to form carbon dioxide. Consequently, during the complete oxidation of a glucose molecule, six molecules of carbon dioxide are produced and six molecules of oxygen are consumed. The overall equation for this reaction is: C6H12O6 + 6 O2 6 CO2 + 6 H2O Because the gas exchange in this reaction is equal, the respiratory quotient for carbohydrate is unity or 1.0: R.Q. = 6 CO2 / 6 O2 Fats The chemical composition for fats differs from that of carbohydrates in that fats contain considerably fewer oxygen atoms in proportion to atoms of carbon and hydrogen. fats are in 6categories: total fats, saturated fatty acid, polyunsaturated fatty acid, monounsaturated fatty acid, dietary cholesterol, and trans fatty acid. From a basal metabolic or resting metabolic perspective, more energy is needed to burn a saturated fatty acid than an unsaturated fatty acid. The fatty acid molecule is broken down and categorized based on the number of carbon atoms in its molecular structure. The chemical equation for metabolism of the twelve to sixteen carbon atoms in a saturated fatty acid molecule shows the difference between metabolism of carbohydrates and fatty acids. Palmitic acid is a commonly studied example of the saturated fatty acid molecule. The overall equation for the substrate utilization of palmitic acid is: C16H32O2 + 23 O2 16 CO2 + 16 H2O Thus the R.Q. for palmitic acid is 0.696: R.Q. = 16 CO2 / 23 O2 = 0.696 Proteins Proteins are composed of carbon, hydrogen, oxygen, and nitrogen arranged in a variety of ways to form a large combination of amino acids. Unlike fat the body has no storage deposits of protein. All of it is contained in the body as important parts of tissues, blood hormones, and enzymes. The structural components of the body that contain these amino acids are continually undergoing a process of breakdown and replacement. The respiratory quotient for protein metabolism can be demonstrated by the chemical equation for oxidation of albumin: C72H112N18O22S + 77 O2 63 CO2 + 38 H2O + SO3 + 9 CO(NH2)2 The R.Q. for albumin is 63 CO2/ 77 O2 = 0.818 The reason this is important in the process of understanding protein metabolism is that the body can blend the three macronutrients and based on the mitochondrial density, a preferred ratio can be established which determines how much fuel is utilized in which packets for work accomplished by the muscles. Protein catabolism (breakdown) has been estimated to supply 10% to 15% of the total energy requirement during a two hour training session. However, if a person's muscle glycogen supplies are low from previous exercise sessions, the amount of energy derived from protein catabolism could increase from 15% to 45%. This process could severely degrade the protein structures needed to maintain survival such as contractile properties of proteins in the heart, cellular mitochondria, myoglobin storage, and metabolic enzymes within muscles. The oxidative system (aerobic) is the primary source of ATP supplied to the body at rest and during low intensity activities and uses primarily carbohydrates and fats as substrates. Protein is not normally metabolized significantly, except during long term starvation and long bouts of exercise (greater than 90 minutes.) At rest approximately 70% of the ATP produced is derived from fats and 30% from carbohydrates. Following the onset of activity, as the intensity of the exercise

increases, there is a shift in substrate preference from fats to carbohydrates. During high intensity aerobic exercise, almost 100% of the energy is derived from carbohydrates, if an adequate supply is available The respiratory quotient (or RQ or respiratory coefficient), is a unitless number used in calculations of basal metabolic rate (BMR) when estimated from carbon dioxide production. Such measurements, like measurements of oxygen uptake, are forms of indirect calorimetry. It The respiratory quotient (RQ) is calculated from the ratio: RQ = CO2 eliminated / O2 consumed where the term "eliminated" refers to carbon dioxide (CO2) removed ("eliminated") from the body. In this calculation, the CO2 and O2 must be given in the same units, and in quantities proportional to the number of molecules. Acceptable inputs would be either moles, or else volumes of gas at standard temperature and pressure (time units may be included, but they cancel out since they must be the same in numerator and denominator). Many metabolized substances are compounds containing only the elements carbon, hydrogen, and oxygen. Examples include fatty acids, glycerol, carbohydrates, deamination products, and ethanol. For complete oxidation of such compounds, the chemical equation is CxHyOz + (x + y/4 - z/2) O2 ---> x CO2 + (y/2) H2O and thus metabolism of this compound gives an RQ of x/(x + y/4 - z/2). The range of respiratory coefficients for organisms in metabolic balance usually ranges from 1.0 (representing the value expected for pure carbohydrate oxidation) to ~0.7 (the value expected for pure fat oxidation). See BMR for a discussion of how these numbers are derived. A mixed diet of fat and carbohydrate results in an average value between these numbers. An RQ may rise above 1.0 for an organism burning carbohydrate to produce or "lay down" fat (for example, a bear preparing for hibernation). RQ value corresponds to a caloric value for each liter (L) of CO2 produced. If O2 consumption numbers are available, they are usually used directly, since they are more direct and reliable estimates of energy production. RQ as measured includes a contribution from the energy produced from protein. However, due to the complexity of the various ways in which different amino acids can be metabolized, no single RQ can be assigned to the oxidation of protein in the diet. In one breath, you normally breathe in more molecules of oxygen (O2) than you breathe out molecules of carbon dioxide (CO2). The ratio between these CO2 / O2 is the respiratory exchange ratio (RER). Measuring this ratio can be used for estimating the respiratory quotient (RQ), an indicator of which fuel (carbohydrate or fat) is being metabolised to supply the body with energy. RER is about 0.8 at rest with a modern diet. This value however, can exceed 1 during intense exercise, as CO2 production by the working muscles becomes greater and more of the inhaled O2 gets used rather than being expelled. During exercise, using RER for estimating RQ loses accuracy because of factors including bicarbonate buffering of hydrogen ions, which affects the CO2 levels being expelled by the respiratory system. Calculation of RER is commonly done in conjunction with exercise tests such as theVO2 Max Test and can be used as an indicator that the participant is nearing exhaustion and the limits of their cardio-respiratory system. An RER greater than 1.1 is often used as a secondary endpoint criteria of a VO2 Max Test. An RER of 0.70 indicates that fat is the predominant fuel source, RER of 0.85 suggests a mix of fat and carbohydrates, and a value of 1.00 or above is indicative of carbohydrate being the predominant fuel source.

One of the most deceiving phrases in the fitness world is "fat burning zone," which is often found on cardio fitness equipment. This is often misunderstood by fitness enthusiasts as the zone whereby they will burn only fat. Though possibly confusing, the intent was to educate individuals on sources of fuel during different levels of aerobic intensity. Respiratory Quotient The zones were derived from the respiratory quotient, which is the amount of carbon dioxide exhaled and divided by the amount of oxygen inhaled at different aerobic intensities. The RQ helps to determine the contribution of fats and carbohydrates as the source of fuel. As the exercise intensity levels increase, so does the RQ. Fat Burning Zone A low RQ of 0.71 is when the highest percentage of fuel is coming from fat. This level of intensity is comparable to sitting and reading a book. As exercise intensity increases, so does the contribution of carbohydrates. An RQ of 0.85 has an equal mixture of carbohydrate and fat as fuel, and it is often found during moderate exercise at 65 percent of maximum heart rate. This low level of exercise will use a higher percentage of fat as fuel, therefore the "fat burning zone" is found between 65 percent and 75 percent of maximum heart rate. Calories Though fat is often what many want to lose when seeking to reduce weight, we still have to consider the total calorie expenditure. When exercising at a higher RQ or in the "cardio zone," this high intensity exercise uses more calories per minute. Though the percentage of fuel derived from fat has decreased, the total caloric expenditure has increased in a shorter amount of time.

Using the Fat Burning Zone Using this zone is beneficial if you are de-conditioned or have never exercised. When beginning an aerobic training program, it is common to feel out of breath. With regular training, the body will develop a more efficient cardiorespiratory system that is better able to deliver oxygen throughout the body and remove waste. Exercising in the "fat burning zone" will enable you to exercise for longer periods of time, burn the necessary calories and prepare for more intense exercise. Fat Loss If the main goal is to lose stored fat on your body, it is important to factor energy, or caloric, expenditure and not worry if the calories are derived from fat or carbohydrates. Find an aerobic program that is tolerable and allows you to exercise safely. Though a lower intensity program will take more time, it is best to slowly increase intensity and allow your body to acclimate to prepare for more challenging and less time consuming exercises. Respiratory quotient (RQ) or respiratory coefficient is a measurement of the ratio between oxygen (O2) an organism intakes and carbon dioxide (CO2) the organism eliminates, expressed with the formula RQ=CO2 eliminated/O2 absorbed. In order to measure an organism's respiratory quotient, it is necessary to use a device called a respirometer to measure the gases the organism takes in and expresses. This is commonly done inside a chamber, which provides a highly reliable way to monitor the gas levels without causing injury. In order to generate reliable measurements, comparable units have to be used for the oxygen and carbon dioxide levels. Otherwise, the ratio will be skewed and will be less meaningful as a result. Various units of measurement can be used, depending on the organism being studied and the precision of the available instruments. With very fine instrumentation and very small organisms, it is possible to pick up very accurate readings which can be used in respiratory quotient calculations. This ratio reveals what the body is using for energy. On the cellular level, respiration is used to generate new energy for cells by taking nutrients which the organism has consumed and generating a series of reactions to derive energy from those nutrients so that the cell can operate. This also produces waste materials which must be eliminated. One common method for cells to derive energy is aerobic respiration, in which oxygen is used as a catalyst for this process; humans, for example, respire aerobically and rely on oxygen for cell function In an organism which is using fats for energy, the respiratory quotient is around 0.7. Burning proteins for energy generates a respiratory quotient of 0.9, while carbohydrate consumption generates a perfect 1.0. If an organism's respiratory quotient rises above 1.0, it is an indicator that the organism is relying on anaerobic respiration for energy. This information can be used to gather data about someone's metabolism in the course of a diagnostic evaluation used in medical treatment to collect information about a patient which can be used by a doctor to learn more about why a patient is feeling unwell. In a health setting, tests may be run to determine someone's respiratory quotient for the purpose of calculating basal metabolic rate, which reflects the amount of energy someone uses when he or she is at rest. Variations in basal metabolic rate can be used to assess general health and identify errors in metabolism which may be causing symptoms of ill health.

II: PRINCIPLE of NUTRIENT UTILIZATION

Adequate nutritional support, that is, adequate provisions of energy and protein substrate, is an essential aspect of the management of the surgical patient. The use of nutrients by the cell for energy and tissue synthesis requires an adequate delivery of oxygen to the cells. Maintenance of tissue, oxygen, delivery, and hemo-dynamic stability are essential for nutritional management. Energy requirements are defined in terms of the calorie. One calorie is the energy required to increase the temperature of 1 gram of water by 1 degree centigrade. The calorie used to define human metabolic needs is actually a kilocalorie (1000 calories). Protein requirements are defined in terms of nitrogen needs, nitrogen making up about 15 percent of a protein. The respiratory quotient (RQ) is the ratio of carbon dioxide production during metabolism to the amount of oxygen consumed. RQ equals CO2 produced (Moles) /O2 consumed (Moles). The RQ value for carbohydrate is 1.0, for fat 0.7 and for protein 0.8: The grams of nitrogen in protein = grams of protein/6.25. The calorie: nitrogen ratio is the number of calories per gram of nitrogen. Nutrient Carbohydrates Fats Proteins A: CARBOHYDRATE METABOLISM Carbohydrate is the primary fuel in man accounting for 60-70% of calories. In its anhydrous form 1 gram of carbohydrate generates 4 calories. However, carbohydrate is stored and used, for example, in solution in its hydrated form from which 3.4 calories is generated per gram metabolized. Insulin is required for glucose to enter the cell to be used for energy. Only small amounts of glucose are stored. About 150 grams can be stored in the adult liver and 300 grams in muscle as glycogen, which can be rapidly mobilized to glucose for when needed. Glucose requires phosphorylation to initially enter the cell, and it cannot subsequently leave that cell. The total number of stored glucose calories is less than 1500 in the normal adult. Excess glucose cannot be stored beyond that which is needed for energy and a small amount of glucogen which tissues can use. Excess glucose is rapidly conversed to fat. This process requires energy, and the respiratory quotient exceeds 1.0, resulting in a marked excess I carbon dioxide production. Glucose + O2 = CO2 + Energy (RQ=1.0) Glucose (excess) + Energy = Fat + CO2 (RQ=8) Carbohydrate cycling occurs with the stress response, via activation of the Cori cycle. Carbohydrate to lactate and back to carbohydrate. This process yields only a fraction of the ATP produced with the complete burning of carbohydrates to CO2 and water. In addition, the hormonal stimulus for gluconeogenesis exceeds demands and a relative insulin resistant state is present due to elevated antiinsulin hormone activity. Providing sufficient carbohydrate (60% of total calories) is still necessary to attenuate the drive to breakdown protein with amino acids used to make glucose. B: FAT METABOLISM Fat is used fuel in unstressed man, accounting for about 30-40 percent of the calories, depending on the diet. Fat is used for 85-90% of fuel in starvation. Fat is composed of triglycerides, which in turn comprise glycerol and fatty acids. The glycerol is burned like carbohydrate, while the fatty acids enter the Krebs cycle via a process called beta-oxidation whereby two carbon segments are cleaved off. Ketones are then produced. The ketones enter the Krebs cycle as acetylcoenzyme A, generating energy at a respiratory quotient of 0.7 with 9 to 10 calories per gram of fat. Increased ketosis signals the predominant use of fat Calories/gm 4 (3.4 hydrated) 10 4

through ketones for energy. This situation is seen in the starved surgical patients with a lack of available carbohydrate where ketones become the predominant fuel. With a large carbohydrate load, fat utilization is depressed. In addition to the availability of carbohydrate, fat breakdown is dependent on the endocrine environment. Insulin decreases the utilization for energy in preference to carbohydrate while catecholamines, and growth hormone increase fat breakdown. The number of available calories in stored fat in the normal adult with 10 kg of fat is about 100,000 about 100 times more than that in stored carbohydrate. With the stress response fat is not used to decrease amino acid use for energy. Instead there is an increase in the cycling of fatty acid to fat and back. However, fat may provide up to 50% of fuel in the absence of adequate carbohydrates. Ketosis is not usually seen in the stressed surgical patient reflecting the decreased fat utilization compared to that seen in starvation.

: PROTEIN METABOLISM In normal man, almost all the energy comes from carbohydrate and fat as long as they are present in sufficient amounts in the diet. With a carbohydrate or fat deficit or a protein excess, the amino acids are metabolized to produce calories. Approximately 4 calories are generated per gram of protein. Normally for every 300 calories, 1 gram of nitrogen (6.25 grams of protein) is ingested in the normal diet, the majority of the nitrogen being used for protein synthesis. With surgical trauma, or infection and its altered endocrine and inflammatory environment, more than 20 percent of the total energy comes from the use of protein as fuel. The RQ value for protein is 0.8. The three branched chain amino acids (valine, leucine, and isoleucine) can be utilized directly by tissues for energy via the Krebs cycle and mitochondria. The remaining amino acids require deamination in the liver with conversion to keto-acids which can be transported to all tissues for burning using the Krebs cycle. Protein synthesis is vital in the maintenance of the integrity of all cells, in particular those that have a rapid protein turnover. Deamination of amino acids in the liver leads to liver urea production. Adequate renal clearance is necessary to avoid a rapid increase in the blood urea concentration, especially during a catabolic state. The rate of protein synthesis depends on the available amino acid substrate, tissue demands and the hormonal environment, especially the activity of anabolic hormones. Sufficient protein intake in the form of amino acids is necessary to keep up with necessary new protein formation and net losses seen in the surgical patient. In a normal uninjured man this usually requires about 1 gram of nitrogen (6.25 grams of protein) for every 300 calories less than 1 gram of protein per kilogram of body weight. With increased tissue demands and the increased use of protein for energy, as seen in injured patients, protein needs, increase to approximately 1.5 grams per kilogram of body weight, with a ratio of calories to nitrogen of 100:1 to as low as 80:1. Growth hormone, androgens, and insulin increase protein synthesis, whereas glucocorticoids and the catecholamines increase protein breakdown. D: MICRONUTRIENT METABOLISM Micronutrients are essential for cellular function. They are called nutrients because of their key role in metabolism, but these of their key role in metabolism, but these compounds and elements also are involved in many other aspects of homeostasis, including wound healing, antioxidant protection, and immune function. The term micro is used because of the extremely small amounts found in the circulation tissues. Their concentration is critical to cellular function. Micronutrients usually are divided into the organic compounds (vitamins) and inorganic compounds (trace minerals). The micro-minerals are used in a variety of metabolic pathways often used as co-factors for enzymatic reactions. Both need to be provided and both are utilized and lost in increased quantities to metabolic response to stress seen in the surgical patient. Deficiency states therefore can occur easily. Because measurement of adequate levels is difficult, if not impossible, prevention of a deficiency often is accomplished only by increasing intake. Vitamins are organic substances that are essential in humans for growth and homeostasis A few of their

characteristics are: y y y y Essential organic micronutrients involved in fundamental body functions. Supplied mainly by food. Each vitamin has multiple, unrelated functions. No chemical relationship among the group.

The term Vitamin was first used by a biochemist who discovered one of the first of these essential elements, which happened to be an amine, thus vitamin. Vitamins are found in very small quantities in the body. Each has a name defined by a letter as well as a chemical name. These compounds play a key role in metabolism, growth, and homeostasis and therefore are especially important in surgical critical illness, in which hypermetabolism, healing, and immune function are so important for survival. A deficiency state, which can occur readily, clearly will amplify the magnitude of disease. It is important to point out that trace elements are absorbed from food and mineralized water, which means an intact, functioning gut and food intake are critical. Tube feeding solutions and TON contain insufficient quantities of these nutrients for the critically ill. The addition of trace elements in increased amounts to enteral and parenteral feeding regimens is of major importance in managing the surgical patient considering their importance in metabolism, healing, and immune defenses.