Medical Nutrition Therapy

for Neuropsychiatric
disorder

SURYANI AS’AD
CLINICAL NUTRITION DEPT.
SCHOOL OF MEDICINE
HASANUDDIN UNIVERSITY
 STROKE
 EATING DISORDER
 ANOREXIA NERVOSA
 BULIMIA NERVOSA
 LEARNING OBJECTIVES
 UNDERSTAND NUTRITIONAL ASPECTS OF
STROKES
 APPLY NUTRITIONAL MANAGEMENTS OF
PATIENTS STROKES
 understand the differences between various
eating disorders e.g. anorexia and bulimia
nervosa.

 consider causative factor presenting features, at

risk groups, medical complications, prevention
and treatment
NUTRITION MANAGEMENT ON STROKE
INTRODUCTION

STROKE

Symptom or sign brain disfunction, local

or systemic , acute, progressive, caused
of death. Originally came from Vasculer
disease w/o trauma, infection
 stroke

Caused of death and disability

in the world

3rd rank after CVD and cancer

Integrated therapy
1st caused of death at hospital Intervention medis
in Indonesia and nutrition

Prediction-- 2020 ↑ 2x fold

  holistic stroke management

 METABOLISME disturbance on STROKE

Stroke  Complex
Part of critically
neurological metabolism
ill.
diseases Respon

Involved all Respon

metabolim critically ill: ebb
pathway and fase flow.
 RISK FACTORS

Modifiable Nonmodifiable

HT, CVD, DM,

hyperlipidemia,,
Age, sex, race
and stenosis
arteri carotis

Smoking, alcohol
consumption , Genetic factor
physical activity
 Flow Phase

Metabolic
Respon

Ebb Phase
Adaptation

Day 7
Time
12-24
hours I
Figure 2; metabolic respon on stroke
Table 1: Characteristic of metabolic phase occurring after severe injury
EBB PHASE FLOW PHASE
RESPONSE Acute response Adaptive response
Hypovolemic Catabolism Anabolism
Shock predominates predominates
Glucocorticoid
Tissue perfussion
Glucagon Hormone response
 metabolic rate Cathecolamine, gradually diminish
Oxygen Consump. Release of cytokines, lipid Hypermetabolic rate
mediators, Associated with recovery
Blood pressure Production of acute phase Potential for restoration of
Body temperature protein body protein
Excretion of nitrogen Wound healing depends in
Metabolic rate part on nutrient intake
Oxygen consumption

Impaired utilization of fuel

Source: Krause’s FOOD,NUTRITION & DIET THERAPY, 1996

STROKE food disability  -  nutritionsl status
and nutrition need
- special diet
 Stroke management
 General:
5 B (breathing, blood, brain, bladder, bowel),
 Drug therapy (brain protection)
 Risk factor and complication
 Rehabilitation medic.

 Specific:
1. stroke non hemorrhagic: asetosal, neuroprotektor,
trombolisis, antikoagulan.
2. stroke hemorrhagic: neuroprotector, operation,
decreased intracanial pressure.
 NUTRITION THERAPY

GOAL NUTRITIONAL STATUS

Nutritional History
 Maintain neurological
function anthropometric,
 Prevent loss LBM physical/clinical sign
 Optimal fasilitated normal lab assessment,
body function
 Identification malnutrition

Anthropometric Clinical
laboratorium
BMI assessment

bioelectrical subjective global

impedance assessment
analysis (BIA). (SGA)
Metabolic Stress

Hypoksia,
Inflamation, Respons:
Necrosis, Local
Trauma Systemic
Infection
 NUTRITIONAL CHANGES

 unconcioussness, Decreased intake increased need

 dysphagia,
 Parese ,
 Decreased MALNUTRITION
mobility
 Pain – swallowing .
protein deficiency
Hypoalbuminemia ≈
indicator mortality &
functional ability post-
stroke

Decision—nutrition therapy –milestone on management stroke.

 compication :
aspiration →
Complication
Risk to
pneumonia
disphagia +
45%-55%
pneumonia →
stroke acute
bad prognosis

Disphagia
 Dysphagia symptom
• Hypersalivation
• Cough when eating
• Disable to suck drink
• Keep food at mouth
• gag reflek negatif,
• Chronic Upper up respiratorius infection
Nutrition requirement

Measurement
Calorie need

Indirect calorimetry
Harris Benedict

Total calorie
BEE x IF x AF
 CALORIE NEED BSED ON
HARRIS BENEDICT EQUATION

• BEE = 66 + 13,7 W + 5 H – 6.8 A

MALE

• BEE = 655 + 9.6 W + 1.7 H – 4.7 A

FEMALE
 STEP
Acute phase (24-48 jam): unconcious

parenteral (NPO)

enteral (nasogastric tube/NGT)

Bila perdarahan lambung - dan cairan lambung (CMS) < 200 ml

Bila perdarahan +, untuk sementara diberikan makanan parenteral

sampai perdarahan berhenti dan CMS < 200 ml dalam 6 jam.

Semua pasien stroke harus diperlakukan sebagai pasien dengan ggn

menelan sampai terbukti tidak

Recovery phase (Sudah sadar, disfagia –)

Makanan diberikan per oral secara bertahap
 ACUTE PHASE: PROTEIN 15-20%
Energy 1100-1500 kkal/day 1,2-1,5 g/kgBB/Day

CHO minimal 150 g FAT 2 g/kg/BW/dayatau

atau 50-65% KET 20-30%

National Cholesterol Education Program (NCEP)

lemak < 30% total energi, SFA <7%, MUFA<15%. PUFA)
<10% dengan cholesterol < 200 mg.13,15
 FLUID:
minimal 1500 ml FIBER
per hari

Supplementasi Bentuk makanan

vitamin dan sesuaikan
mineral keadaan pasien

demam,
porsi kecil dan
tambahkan
sering
sebesar 13%
 MONITORING

Kadar Elektrolit Dalam Darah

Na, K, Cl Hco3, Calsium

Analisa Gas Darah

NUTRITIONAL APROACH

Enteral Nutrisi

Parenteral Nutrisi
(Perifer atau Sentral)

Kombinasi Enteral +
Parenteral
INDIKASI NUTRISI Penilaian Nutrisi 
ENTERAL DAN Keputusan untuk memulai Dukungan Nutrisi Khusus
PARENTERAL Fungsi Saluran Pencernaan

Ya Tidak

Nutrisi Enteral Nutrisi Parenteral

Jangka panjang Jangka pendek
Gastrostomi Nasogastrik
Jejunostomi Nasoduodenall Jangka panjang atau
Jangka pendek
Nasojejunal Pembatasan cairan
 
Fungsi Sal Cerna Nutrisi Nutrisi
Parenteral Perifer Parenteral Total
Normal Compromised

Nutrisi Lengkap Formula Khusus

 Fungsi saluran
cerna membaik
Nutrients
Tolerance 
Mencukupi Mencukupi Tidak
Tidak mencukupi Ya
Berlanjut ke Diet yg lebih
Makanan Nutrisi parenteral Kompleks dan
Sebagai suplemen Sumber: ASPEN Board of Directors
Oral Makanan oral
Guidelines for the use of Parenteral and
Sesuai dengan
Enteral Nutrition in adult and pediatric
penerimaan
Dilanjutkan ke nutrisi Patients. JPEN 1993: 17.
Enteral total
NUTRITIONAL ENTERAL BENEFIT
Ekonomis

Memacu sekresi hormon pencernaan

Tanpa resiko sepsis kateter dan flebitis.

Menghambat pertumbuhan bakteri dan

translokasi bakteri

Mencegah atrofi villi

Heimburger, Douglas C. Handbook of Clinical Nutrition. Mosby, 1997. P 209 – 211.

EATING DISORDER
ANOREXIA NERVOSA,

BULIMIA NERVOSA
Objectives

 To understand the differences between

various eating disorders e.g. anorexia and
bulimia nervosa.

 To consider causative factor presenting

features, at risk groups, medical
complications, prevention and treatment.
Eating Behaviors

 Why do we eat?
Internal – hunger
Energy external – pleasure, social, personality,
environment

 What is abnormal eating behavior?

Abnormal eating behavior = eating disorder?
 Why do we stop eating ?
We stop eating when we are satisfied?

 Eating is a behavior Not necessarily related to

hunger or fullness
 Many of us, occasionally eat until we’re
stuffed and uncomfortable

any age
Some
both sex, Obesity - controlling people must go
Over any --chronic too little
Progressive food intake are beyond
socio- diseases physical
eating weight gain and body more nutritional
economic —most activity
weight suscep therapy
/ class / common
tible
ethnicity
 From ordered to disordered eating habits

religion
• completely meanings • expressing love,
instinctive behavior • hatred or even
• physiological, • express hostility, power
• social and culture • affection,
• prestige or class
values
bonds within
Eating
family
In Fact: Media, Audiovisual Influences

Ultra slim body

Contradictory
will bring;

Happiness Much
Love society

Ultimately Becoming
success fatter/obese
 FOOD: MORE THAN JUST A SOURCE OF
From birth – adult NUTRIENTS

Food

Eating
stimulate
neurotransmitter

Stress
food link with (serotonin) and
be symbol of natural opioids some
personal and comfort
emotional (endorphins) people turn
experiences to food for
produce a sense a drug like,
of calm and calming
euphoria in the effect
human body
Using food as a bargaining:
Extreme—lead to Disordered Eating:
disordered eating lead to weight loss or
weight gain
Mild or short term Certain nutritional
Contributing to change –effect of problems
abnormal eating stressful or illness or Requires in depth
behavior desire to modify the professional attention.
diet for variety of Sustained, distressing---
health and personal professional intervention
appearance reason
 ANOREXIA NERVOSA

• an eating disorder involving a

physiological loss or denial of
appetite, followed by self starvation;
related in part to distorted body
image and to various social pressure
commonly associated with puberty
 BULIMIA NERVOSA
An eating disorder in
which large quantities
of food are eaten at one Alternate means to
time (binge eating) and counteract the binge
then purged from the behavior are fasting
body by vomiting or and excessive exercise
misuse of laxative,
diuretics or enemas
Binge Eating Disorder
An eating disorder
characterized by Can be triggered by
recurrent binge frustation, anger,
eating and feelings of depression, anxiety,
loss of control over permission to eat
eating that have forbidden food and
lastest at least 6 excessive hunger
months
 Progression from Ordered to Disordered
Eating

Anxiety to hunger and satiety signal;

limitations of calorie intake to restore
weight to healthful level

eating habits begins as weight loss is

attempted– very restricted eating

Clinically evident eating disorder

recognized
Medical Complications of Anorexia Nervosa
and Bulimia Nervosa
• Cardiovascular: • Dermatologic:

Hematologic Metabolic:

Complication Musculoskeletal

• Endocrine • Gastrointestinal
 Felling of panic after
small weight gain False body perception Loss weight >85% ---
Felling of purity, Ritual involving food BMI <17,5
power, and superiority

Lack of menstrual Preoccupation of food

Maintain of rigid
periods for at least 3 control in lifestyle Helplessness in the
months presence of food

Typical Characteristic
of Anorexia Nervosa
 Muscle tears and
stress fractures in Loss of teeth—acid
Iron deficiency anemia athlete--- decreased erosion
bone and muscle mass

Low blood
Loss of menstrual potassium—heart
periods Constipation rhythm disturbance—
death

Physical effects of Anorexia

Nervosa
 Treatment of Psychological and
Anorexia nervosa Nutrition therapy
related therapy

Gain the persons Emotional problems

Food is a drug of choice cooperation
for anorexic patient
and trust
Family therapy
Use cognitive behavior
therapy
MAINTAIN ADEQUATE Gain weight 2-3
Monitoring blood levels
FOOD INTAKE pounds/weeks
of mineral (K, PO4, Mg)
 Bingeing on a large of food
followed by fasting, Fluctuating weight
Erotion of teeth,
laxative or diuretic abuse, Purchase of syrup of ipecac
swollen glands eslf induce vomiting or to induces vomiting
excessive exercise

Secretive binge eating( not

in front of others)
Perfectionism ; “people Loss of control, fear of not
pleaser” embarassment, deceit and
being able to stop eating
depression, low self
esteem and guilt

Typical Characteristics
of Bulimia Nervosa
 Ipecac syrup
induced vomiting— Salivary gland
Constipation
is toxic to the heart, swollen
liver and kidneys

Demineralization of
Stomach ulcer and Blood potassium
bleeding teeth as an impact drops significantly
of the acid in vomit

Health Problems Stemming

from Bulimia Nervosa
Treatment of Nutrition
Pharmacological
Bulimia Psychotherapy counseling therapy
Nervosa
Decreased the improved self
Correcting
amount of food acceptance –less
misconceptions may be
consumed in concern about
about food beneficial in
binge session body weight
conjunction
with other
DEVELOPING Re-establishing therapy
Cognitive
REGULAR regular eating
behavior
EATING HABITS habits