Nutrition in Neurologic Disorders: A Practical Guide

209 Pages·2017·2.716 MB·English

by  Ethem Murat Arsava (eds.)

Ethem Murat Arsava
Editor
Nutrition in
Neurologic Disorders
A Practical Guide
123
Nutrition in Neurologic Disorders
Ethem Murat Arsava
Editor
Nutrition in Neurologic
Disorders
A Practical Guide
Editor
Ethem Murat Arsava
Hacettepe University
Faculty of Medicine
Ankara
Turkey
ISBN 978-3-319-53170-0 ISBN 978-3-319-53171-7 (eBook)
DOI 10.1007/978-3-319-53171-7
Library of Congress Control Number: 2017939690
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Preface
There is a very close and multidimensional interplay between nutritional status and
neurologic diseases. On one hand, nutritional problems can predispose to certain
neurologic disorders. On the other hand, both acute and chronic neurological disor-
ders have a significant impact on body metabolism. In addition, these patients com-
prise a high-risk group who can rapidly develop malnutrition secondary to their
disabilities related to manifestations of the underlying disease, like swallowing
problems or mobility issues. Malnutrition, unless prevented or efficiently treated, is
a well-known factor that contributes to increased morbidity and mortality in patients
with neurologic diseases. Despite its importance and high prevalence, neurologists
are generally not motivated in implementing nutritional plans to their patients. One
contributing factor in this regard is the scarcity of publications that primarily focus
on the issue of nutritional management of neurological patients.
In this publication, we aim to cover practical aspects of nutrition from a neurol-
ogy perspective. The book starts with a concise review of macronutrient metabolism
in the human body and familiarizes the reader on how this highly critical body func-
tion is disturbed in disease settings. The section is followed by a detailed summary
of commonly used screening and assessment tools in identifying patients with mal-
nutrition, where the normal physiology has been exhausted by impaired food and
calorie supply. Epidemiologic facts on nutritional issues in neurological disorders
and their impact on the disease course, discussed in the ensuing chapter, highlight
the importance why nutritional evaluation and planning should be inherent tasks of
neurologists. The part on methods of clinical nutrition presents basic knowledge on
the principles of how these plans should be implemented. Specific chapters dedi-
cated to nutritional support in neuro-intensive care unit patients and patients with
amyotrophic lateral sclerosis and chronic neurodegenerative diseases provide a
handy guide for nutritional management of neurologic patients encountered in vari-
ous clinical settings. The concept of dysphagia, a critical and highly prevalent con-
tributor of disease-related malnutrition among neurology patients, is discussed
extensively from a multitude of aspects including its pathophysiology, diagnosis,
treatment, and rehabilitation. Our work is finalized by a chapter on the newly devel-
oping and provoking concept of neuro-nutrition—the use of certain nutrients for the
treatment of neurologic disorders—an area where the scientific community has kept
its distance for a long time but could not avoid anymore due to the immense pres-
sure from the lay media and general public.
v
vi Preface
We believe that this work would be an important resource for filling the gap in
the field and would prove to be useful not only for practicing neurologists but also
for medical personnel from other fields like clinical nutrition, critical care, or geri-
atric medicine. We hope that the book will meet the expectations of our valuable
readers.
Ankara, Turkey Ethem Murat Arsava
Contents
1 Metabolism of Macronutrients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Lubos Sobotka
2 Screening and Assessment of Malnutrition . . . . . . . . . . . . . . . . . . . . . 19
Miguel León-Sanz and Maria Angeles Valero
3 Malnutrition in Neurological Diseases . . . . . . . . . . . . . . . . . . . . . . . . . 39
Levent Gungor
4 Methods of Clinical Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
R. Haldun Gundogdu
5 Nutritional Support in the Neurointensive Care Unit . . . . . . . . . . . . . 77
Imad Khan, Sundeep Bojedla, and Neeraj Badjatia
6 Nutritional Support in Amyotrophic Lateral Sclerosis . . . . . . . . . . . . 91
Theocharis Stavroulakis and Christopher J. McDermott
7 Nutritional Support in Chronic Neurodegenerative Diseases . . . . . . . 105
Rainer Wirth
8 Pathophysiology, Diagnosis, and Medical Management
of Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Francesco Mozzanica, Nicole Pizzorni, and Antonio Schindler
9 Dysphagia Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Selen Serel Arslan, Numan Demir, and Aynur Ayşe Karaduman
10 Neuronutrition: An Emerging Concept . . . . . . . . . . . . . . . . . . . . . . . . 155
Mehmet Akif Topcuoglu and Ethem Murat Arsava
vii
Metabolism of Macronutrients 1
Lubos Sobotka
1.1 Introduction
Almost all energy, which circulates within life cycles, originates from the Sun. The
green plants accumulate energy of the Sun into substrates which are composed of
carbon, hydrogen, oxygen, and nitrogen supplemented with relatively small amounts
of other atoms (electrolytes and trace elements). The animals ingest, metabolize, and
oxidize such plant substrates, which are called macronutrients; some animals (includ-
ing humans) eat macronutrients that originate from both plants and animals.
Appropriate and adequate nutrition is absolutely essential for animal life. If the
intake of nutrition is interrupted, the energy necessary for survival is obtained from
body reserves; such a situation is called negative energy balance. A long-term nega-
tive energy balance leads to body depletion, the loss of 30–40% of body proteins is
life-threatening. Such a fatal loss of body mass occurs after 50–70 days of uncom-
plicated fasting; however, during periods of critical illness, this interval is consider-
ably shorter due to reduced adaptation to negative energy balance and increased
protein catabolism.
There are three main components of nutrition:
– Macronutrients—carbohydrates, lipids, and proteins
– Water and electrolytes (Na, K, Ca, Mg, Cl, P)
– Micronutrients—vitamins and trace elements
Quantitatively, macronutrients constitute the largest part of nutrition; however,
they are not solely sources of energy, as usually declared. Macronutrients are also
the source of substrates necessary for body development, growth, protection against
L. Sobotka
3rd Department of Medicine, Metabolic Care and Gerontology, Medical Faculty Hradec
Kralove, Charles University in Prague, 50005 Hradec Kralove, Czech Republic
e-mail: [email protected]
© Springer International Publishing AG 2017 1
E.M. Arsava (ed.), Nutrition in Neurologic Disorders,
DOI 10.1007/978-3-319-53171-7_1
2 L. Sobotka
injury or microbial invasion (inflammation and immune reaction), wound healing,
recovery after disease, rehabilitation, and adaptation.
1.2 Carbohydrates
Carbohydrates (CHOs) are quantitatively the biggest part of energy in a normal diet;
they meet 40–55% of the daily energy intake. Subjects with moderate activity (2500 kcal/
day) should consume 300–400 g of CHOs per day, while very active individuals may
need up to 60% more than these amounts. It is generally suggested that CHOs are the
basic source of energy for organism; however, they do not only serve as energy sub-
strates. Especially glucose possesses several metabolic functions in various cells, tis-
sues, and organs, and its metabolism is much more complex than just provision of
energy. This is apparent from the several possibilities present in glucose metabolism.
Key pathways of glucose metabolism are:
• Krebs cycle—full and effective oxidation of glucose to CO and HO with sub-
2 2
sequent production of energy in the form of ATP.
• Cori cycle—glycolysis and subsequent gluconeogenesis—glycolysis is the
source of energy in ischemic tissues or tissues without oxidative metabolism
(e.g., absence of mitochondria).
• Anaplerotic reactions—reloading metabolites for Krebs cycle.
• Cataplerotic reactions—removal of metabolites from Krebs cycle for biosynthe-
sis of many other molecules (mostly amino acids).
• Pentose cycle—production of:
– Reducing equivalents (NADPH) for synthetic reactions
– Reducing equivalents for free radical scavenging
– Ribose for nucleic acid synthesis
• Synthesis of extracellular matrix and glycocalyx.
• Glycation of physiologically active proteins (e.g., membrane receptors and
transporters).
All these roles are important for life, defense reactions—inflammation, recovery
from disease and rehabilitation, and growth or repletion of body compartments in
severely depleted patients. CHOs are also important for preservation of tissue pro-
teins by reducing the need for gluconeogenesis from amino acids. Moreover, glu-
cose is an important regulatory factor in lipid metabolism; it reduces lipid oxidation
and ketogenesis and also stimulates storage of triglycerides in adipose tissue.
1.2.1 Carbohydrates as Energy Substrate
Most cells of the body, including the central and peripheral nervous systems, as well
as blood cells and ground substance of healing tissues, may use glucose as energy
substrate. The complete oxidation of one mole of glucose to water and CO yields
2
36 moles of ATP and two moles of guanosine triphosphate (GTP). On the other side,
1 Metabolism of Macronutrients 3
glycolysis generates only two moles of ATP and two moles of lactate, which is fur-
ther metabolized in the reverse pathway of glycolysis (gluconeogenesis) to glu-
cose—this cycle is called Cori cycle. Gluconeogenesis from lactate requires six
moles of ATP; it means that energy balance of Cori cycle is minus 4 ATP, derived
from fatty acid oxidation in the liver.
Glucose is a substrate, which can be fully oxidized in most tissues; however, it is
not fully oxidized during hypoxia when glycolysis with subsequent lactate produc-
tion is the leading pathway of energy production. Red cells and tubular cells in the
kidney fully rely on glycolysis for ATP generation.
Dependence on glycolysis as basic energy-producing reaction is usually due to:
– Absence of mitochondria—red blood cells
– Hypoxic conditions in some organs—renal medulla, all tissues during hypoxia
Glycolysis is also present in rapidly proliferating cells even if oxygen provision
is normal (see below).
Glucose is preferably oxidized in the central nervous system, probably due to
poor permeability of the blood–brain barrier for fatty acids bound to albumin.
However, during prolonged fasting, more than 60% of brain energy is obtained from
oxidation of ketone bodies [1]. Moreover, glucose is not fully oxidized during short-
age of CHOs in the diet, although glucose cycling is still present in this situation [2].
1.2.2 Nonenergy Roles of Carbohydrates
Glucose is not only an energy substrate but also is an important substrate for body
growth, tissue regeneration, immune cell proliferation, and other synthetic pro-
cesses, as well as antioxidative reactions.
Rapidly proliferating cells exhibit a low activity of oxidative metabolism of glu-
cose; this phenomenon was first described for cancer cells as the Warburg effect [3].
The presence of this effect (non-oxidative glucose metabolism in the presence of
oxygen) was later demonstrated in other rapidly proliferating cells. The metabolism
of these cells is changing from full glucose oxidation in the quiescent state to gly-
colysis and enhancement of non-oxidative glucose metabolism in the proliferating
state. Insulin resistance and glucose cycling are also present in other situations when
rapid cell proliferation is necessary (immune cells during inflammation, regenerating
organs, growth, anabolic processes) [4]. Proliferating enterocytes are good examples;
they utilize glucose, however this substrate is not consumed only as a source of
energy production, but glucose is also substrate for anaplerotic and then cataplerotic
reactions. Proliferating cells can use fatty acids as sources of energy and partially
metabolize glutamine (producing aspartate, glutamic acid, pyruvate, and NH).
3
Glucose is the principal substrate for the pentose phosphate pathway (PPP or
pentose cycle). This cycle provides crucial reducing equivalents (NADPH) for
maintenance of the redox state and also for synthetic processes. The PPP is also
indispensable for synthesis of pentoses, which are important for production of
nucleic acids and cell division [5].