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, include determining 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 defieciencies in the
primary care settings.
12. Explain the basic concepts and principles of enteral and parenteral (IntraVenous) nutrition.
Curriculum content
1.
2.
3.
4.
5.
6.
7.
8.
9.
Role and food sources of nutrients
Need of general nutritional and energy requirements in specific physiological conditions
Macro and micronutrients
The concept of well-balanced diet and it’s implementation
Assessment of general nutritional status that has been used in community as well as in
clinical setting
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
The principles of medical nutritional therapy (MNT)
The principles of enteral and parenteral nutrition
Food Supplement and Functional Food
Udayana University Faculty of Medicine, DME
1
Study Guide Clinical Nutrition & disorders
~ 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
DEPT
PHONE
~ LECTURERS ~
NO
NAME
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
08122344895/03
617405330
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. I Gst Lanang Sidiarta, SpA.(K) (IGLS)
Pediatrics
08123966008
6
dr. I Wayan Gede Sutadarma, M.Gizi, Sp.GK
(SUT)
Biochemistry
082144071268
Udayana University Faculty of Medicine, DME
2
Study Guide Clinical Nutrition & disorders
~ FACILITATORS ~
Regular Class
NO
1
2
3
4
5
6
7
8
9
10
11
12
NAME
dr. I Putu Kurniyanta, Sp.An
dr. Tjok. Istri Anom Saturti,
Sp.PD
dr. Herman Saputra, Sp.PA
dr. Yuliana, M Biomed
dr. I.B. Krisna Jaya Sutawan,
Sp.An, M.Kes
dr. Ida Ayu Sri Wijayanti,
M.Biomed, Sp.S
Dr.dr. I G A Sri Mahendra Dewi,
Sp.PA(K)
dr. Ryan Saktika Mulyana,
M.Biomed, Sp.OG
dr.A.A. Ayu Dwi Adelia Yasmin,
M.Biomed, Sp.JP,FIHA
dr. I Made Dwijaputra Ayustha,
Sp.Rad
dr. I Made Oka Adnyana, Sp.S
(K)
dr. I Gusti Agung Gd Mahendra
Wijaya, Sp.Onk,. Rad
GROUP
A1
A2
A3
A4
A5
A6
A7
A8
A9
A10
A11
A12
DEPT
PHONE
ROOM
Anasthesi
081805755222
Interna
081916253777
Pathology
Anatomy
Anatomy
081338981853
Anasthesi
08123836470
Neurology
081337667939
Pathology
Anatomy
Obgyn
081338736481
Cardiology
087861402169
Radiology
08123670195
Neurology
0817347697
Radiology
08990179750
3rd floor
R.3.01
3rd floor
R.3.02
3rd floor
R.3.03
3rd floor
R.3.04
3rd floor
R.3.05
3rd floor
R.3.06
3rd floor
R.3.07
3rd floor
R.3.08
3rd floor
R.3.20
3rd floor
R.3.21
3rd floor
R.3.22
3rd floor
R.3.23
DEPT
PHONE
ROOM
Interna
085237068670
Anasthesi
081338568883
Microbiology
08123921590
Pathology
Anatomy
Radiology
08113803933
081337165566
Interna
08123985811
Andrology
08123979397
Physiology
081338505350
Public Health
0818357777
Biochemistry
081338338611
Opthalmology
08123846995
Psychiatry
08174709797
3rd floor
R.3.01
3rd floor
R.3.02
3rd floor
R.3.03
3rd floor
R.3.04
3rd floor
R.3.05
3rd floor
R.3.06
3rd floor
R.3.07
3rd floor
R.3.08
3rd floor
R.3.20
3rd floor
R.3.21
3rd floor
R.3.22
3rd floor
R.3.23
085792652363
082147087905
English Class
NO
1
2
3
4
5
6
7
8
9
10
11
12
NAME
dr. I Gede Ketut Sajinadiyasa,
Sp.PD
dr. Kadek Agus Heryana,
Sp.An
dr. Made Agus Hendrayana ,
M.Ked
dr. Ni Putu Ekawati,
M.Repro, Sp.PA
dr. Firman Parulian
Sitanggang, Sp.Rad(K)RI
dr. Ketut Suardamana,
Sp.PD-KAI
dr. I Made Oka Negara,
S.Ked
Dr.dr. I Made Muliarta, M.Kes
Dr.dr. Dyah Pradnyaparamita
Duarsa, M.Si
Prof. dr. Nyoman Agus
Bagiada, Sp.Biok
dr. Anak Agung Mas
Putrawati Triningrat, Sp.M (K)
dr. Lely Setyawati , Sp.KJ
Udayana University Faculty of Medicine, DME
GROUP
B1
B2
B3
B4
B5
B6
B7
B8
B9
A10
A11
B12
3
Study Guide Clinical Nutrition & disorders
TIME TABLE
Days/date
1st day
Tuesday
1 Dec 2015
2nd Day
Thursday
3 Dec 2015
3rd Day
Friday
4 Dec 2015
4th Day
Monday
7 Dec 2015
5th Day
Tuesday
8 Dec 2015
Regular
Class
Time
English Class
08.00-09.00
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
12.00-12.30
12.30-13.30
13.30-15.00
13.30-15.00
11.30-12.00
15.00-16.00
10.00-11.30
08.00-09.00
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
12.00-12.30
12.30-13.30
13.30-15.00
13.30-15.00
11.30-12.00
15.00-16.00
10.00-11.30
08.00-09.00
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
12.00-12.30
12.30-13.30
13.30-15.00
13.30-15.00
11.30-12.00
15.00-16.00
10.00-11.30
08.00-09.00
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
12.00-12.30
12.30-13.30
13.30-15.00
13.30-15.00
11.30-12.00
15.00-16.00
10.00-11.30
08.00-09.00
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
12.00-12.30
12.30-13.30
13.30-15.00
13.30-15.00
11.30-12.00
15.00-16.00
10.00-11.30
Udayana University Faculty of Medicine, DME
Learning Activity
Introduction of
the Theme
Independent
Learning
SGD
Break
Plenary
Student project
Nutrition and Life
Cycle
Independen
Learning
SGD
Break
Plenary
Student project
Well Balance
Diet
Independen
Learning
SGD
Break
Plenary
Student project
Infant and
Children Feeding
Practice
Independent
Learning
SGD
Break
Plenary
Student project
Obesity and
Weight
Management
Independent
Learning
SGD
Break
Plenary
Student project
Place
PIC
Class room
GNIP
Discussion room
Class room
Discussion room
WSR
Class room
Class room
Discussion room
GNIP
Class room
Class room
IGLS
Discussion room
Class room
Class room
GNIP
Discussion room
Class room
4
Study Guide Clinical Nutrition & disorders
6th Day
Thursday
10 Dec 2015
7th day
Friday
11 Dec 2015
08.00-09.00
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
12.00-12.30
12.30-13.30
13.30-15.00
08.00-09.00
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
12.00-12.30
12.30-13.30
13.30-15.00
13.30-15.00
11.30-12.00
15.00-16.00
10.00-11.30
09.00-10.00
08.00-09.00
8th day
Monday
14 Dec 2015
09.00-10.30
12.00-13.30
10.30-12.00
12.00-12.30
12.30-13.30
13.30-15.00
13.30-15.00
11.30-12.00
15.00-16.00
10.00-11.30
09.00-10.00
08.00-09.00
9th day
Tuesday
15 Dec 2015
09.00-10.30
12.00-13.30
10.30-12.00
12.00-12.30
12.30-13.30
13.30-15.00
13.30-15.00
11.30-12.00
15.00-16.00
10.00-11.30
08.00-09.00
10th day
Wednesday
16 Dec 2015
11th day
Thursday
17 Dec 2015
13.30-15.00
11.30-12.00
15.00-16.00
10.00-11.30
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
12.00-12.30
12.30-13.30
13.30-15.00
13.30-15.00
11.30-12.00
15.00-16.00
10.00-11.30
08.00-09.00
09.00-10.30
Udayana University Faculty of Medicine, DME
09.00-10.00
12.00-13.30
Primary Protein
and Energy
Malnutrition
Independent
Learning
SGD
Break
Plenary
Student project
Secondary
Protein and
Energy
Malnutrition
Independent
Learning
SGD
Break
Plenary
Student project
Minerals
Deficiency
Independent
Learning
SGD
Break
Plenary
Student project
Vitamins
Deficiency
Independent
Learning
SGD
Break
Plenary
Student project
Nutrition
Management for
Dyslipidemia and
Hyperuricemia
Independent
Learning
SGD
Break
Plenary
Student project
Food
Supplement
(Functional Food
and Antioxidant)
Independent
Learning
Class room
WT
Discussion room
Class room
Classroom
WT
Discussion room
Classroom
Class room
Discussion room
SUT
Class room
Class room
Discussion room
GNIP
Class room
Class room
WT
Discussion room
Class room
Class room
SUT
5
Study Guide Clinical Nutrition & disorders
12th day
Friday
18 Dec 2015
13th day
Monday
21 Dec 2015
14th day
Tuesday
22 Dec 2015
15th day
Wednesday
23 Dec 2015
15th day
Monday
28 Dec 2015
15th day
Tuesday
29 Dec 2015
10.30-12.00
12.00-12.30
12.30-13.30
13.30-15.00
13.30-15.00
11.30-12.00
15.00-16.00
10.00-11.30
08.00-09.00
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
12.00-12.30
12.30-13.30
13.30-15.00
13.30-15.00
11.30-12.00
15.00-16.00
10.00-11.30
08.00-09.00
09.00-10.00
09.00-10.30
12.00-13.30
10.30-12.00
12.00-12.30
12.30-13.30
13.30-15.00
13.30-15.00
11.30-12.00
15.00-16.00
10.00-11.30
08.00-14.00
08.00-14.00
08.00-14.00
08.00-14.00
08.00-14.00
08.00-14.00
08.00-14.00
Udayana University Faculty of Medicine, DME
SGD
Break
Plenary
Student project
Enteral and
Parenteral
Nutrition
Independent
Learning
SGD
Break
Plenary
Student project
Medical
Nutritional
Therapy
Independent
Learning
SGD
Break
Plenary
Student project
BCS
Nutr assessment
Screening/Food
planning/Food
planning
BCS
Nutr assessment
Screening
Discussion room
Student Project
Discussion room
Final
Examinatiom
Class room
Class room
Classroom
Discussion room
WSR/
PRM
Classroom
Classroom
SUT
Discussion room
Classroom
Skill Lab
Classroom
TEAM
Skill Lab
Classroom
TEAM
TEAM
6
Study Guide Clinical Nutrition & disorders
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, they may 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
Udayana University Faculty of Medicine, DME
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Study Guide Clinical Nutrition & disorders
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 these need 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 was 1 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?
Udayana University Faculty of Medicine, DME
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Study Guide Clinical Nutrition & disorders
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
A 26 years old woman, 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 advises on how to keep the optimal fetal growth and optimal nutrition status of pregnant and
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
Udayana University Faculty of Medicine, DME
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Study Guide Clinical Nutrition & disorders
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 prevent and 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
3. What is the meaning of exclusive breastfeeding and how long should be given?
4. How to start solid foods, when to start solid foods and what kind of foods were given at the
first time?
Self-Assessment
7. Describe some of the nutrient and immunological attributes of breast milk.
8. Describe criteria would you use in selecting an infant formula.
9. Describe when an infant is ready to start eating solid food.
10. List foods that are inappropriate for infants and discuss why they are inappropriate.
11. 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
Udayana University Faculty of Medicine, DME
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Study Guide Clinical Nutrition & disorders
5. Theoritically what is the cause for obesity
6. Should She has to reduce her weight what she need to do.
6th day
PRIMARY PROTEIN and ENERGY 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?
Udayana University Faculty of Medicine, DME
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Study Guide Clinical Nutrition & disorders
Case 3.
A 60 years old vegetarian man, his daily meal consist of sereal, soybean, spinach and some
supplement and never take milk, egg nad other animal base food
Learning task.
1. What your opinion about the quality of protein intake?
2. How does the healing process of the injured tissue in vegan people?
3. If pregnant women is a vegan food pattern what the the possibility risk might happen to the
pregnancy (mother and fetal)?
4. For optimal growth and development, the body need good quality of protein. Why?
5. Explain the kind of protein in the food refer to the amino acid contained?
6. What is the meaning of essential amino acid, conditional essential amino acid
7. Define the reference of protein?
8. What does it mean by biological value of protein? Explain the biological value of different
food protein resources?
9. Explain the term protein-sparing effect.
10. List and describe factors that affect the need on dietary protein!
11. What does it mean by nitrogen balance? How does it relate to protein turn over
7th day
SECONDARY PROTEIN and ENERGY MALNUTRITION
Case 1
A man age 35 year old has lost his weight since two month ago. His previous weight was 65 kg and
his height is 172 cm, but now his weight is 48 kg. He also suffer from chronic diarrhea and coughing
and just very recently his cough followed by blood split. He has had lost his appetite since he felt
sore in his mouth and throat 1 month ago.
He works as a tour guide but beside that he often sell his body to satisfy his client lust.
Learning task
1. Mention what is happening nutritionally to this man
2. Discuss What causing him loose his weight so quick
3. Decribe indicators used to pictures clearly his situation
4. Discuss can we proposed him to get his normal weight again
5. Explain the principal of food intevention that can be given to Him
Case 2
Beny aged 20 months was born in only 2000 grams of weight though he born under aterm
pregnanacy. Her mother was also very thin when carrying on him. He got breastfed but not
exclusive since is also working in the field to support the family life budget. Now his weight is 9 kg
(average weight for his age is 11,8 kg). He often get ill and in the daily life he is very irritable.
Learning task
1. Mention what is happening nutritionally to this infant
2. Discuss risk factors causing him fall into this situation
3. Discuss the progonsis of his particular problem short and long termly
4. Explain the principle of nutritional approach/therapy of this infant
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8th day
MINERALS DEFICIENCY
Case
A 20 years old male suffering from electrical burns since one month ago. Food intake has been
declining due to lack of appetite. Suffered burns not healed so it still looks wet.
Learning task.
1. What kind of mineral might be deficient in this case
2. What other symptoms and signs shall be found out in such cases?
3. What kind of food should be consumed as well as avoided to reverse the condition?
4. Describe the basic concept of essentiality in mineral (trace element)
5. Describe the action (metabolism), function, clinical application, RDI and food resources
of major mineral
6. Describe factors that influence the bioavailability (promoter and inhibitor) and absorption
of particular mineral
9th day
VITAMINS DEFICIENCY
Case
An old lady 65 years old can no longer walk properly since she suffer from bow leg. She has seen a
doctor and was told to have exposed with sun rays in the morning that she has rarely had it before
because of worryness to get dark skin, and also she was ask to drink milk and some fruit mostly
avocado.
Learning Task
1. Mention the vitamin is deficient in this old woman, and explain the risk factors that bring
people to geat it.
2. What this disease is called when it happened in older people as well as the young one
3. Explain symptom and sign of this particular vitamin deficiency either in older people and in
young children
4. What kind of food should be consumed to reverse the condition?
5. Describe the definition and the basic concept of vitamins
6. Describe the basic concept of the difference between water and fat soluble vitamins
7. Describe the action, function, RDI, clinical application, side effect and food resources of fat
soluble vitamins (A,D,E,K)
8. Describe the action, function, RDI, clinical application, side effect and food resources of
water soluble vitamins (B and C)
10th day
NUTRITION MANAGEMENT FOR DYSLIPIDEMIA AND HYPERURICEMIA
Case
Boby 35 year old visits a doctor because he feels he gets heavy chest, feels weak and pain mostly
in his ankle. He has suffer from it for about one week. He is 120 kg weight and 170 height. He likes
eating out and very lazy to do excercise. From his blood test, he finds out that his blood cholesterol
is 300 mg/l and the LDL cholesterol is 200 mg/l and the HDL is 30 mg/l. The triglyceride is 400 mg/l
and the uric acid is 9.
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Learning task
1. Diagnose the situation of this patient
2. Calculate the atherogenic index of this patient
3. Discuss the nutritional approach for this patient
4. Discuss what suggestion shall be given to the patient to get better result
11th day
MEDICAL NUTRITION THERAPY
Case
A 55 years old male was hospitalized to undergo chemotherapy series II nasopharyngeal cancer.
He looked very thin and weak. Decreased food intake due to no appetite. He could not eat solid
food and drink only milk. He lost 15 kg of weight in 2 months with height 170 cm. The current weight
is 40 kg and upper arm circumference of 15 cm. Laboratory results obtained Hb 9 g/dL and albumin
2.5 g/dL
Learning task
1. To confirm the patients diagnose, what kind assessment you have to do?
2. To meet nutrition need of the patients, what other information you need for appropriate
nutrition support?
3. What route of feeding and diet should be considered to promote healing?
4. What kind of supplement to be added to the daily menu of the patient? What is the
reason?
5. How do you arrange the frequency of daily food intake?
12th day
FOOD SUPPLEMENT
(FUNCTIONAL FOOD and ANTIOXIDANT)
Case 1
A 30 year old woman is a very active bank worker. She also works part time and takes a full load of
duty, she is always on to go often grabbing something quick to eat like fast food or skipping meal
altogether. Never the less, she feels confident her health will not suffer because she takes a daily
vitamins and minerals supplement.
Learning Task
1. Is a food supplement warranted in this case?
2. Why or why not?
3. What is your suggestion for the patients?
Case 2
A 50 year old man, come to consult a doctor. Currently he is suffering from hypertension stage 1
and hypercholesterolemia. On physical examination found that body weight 85 kg, height 165 cm,
and abdominal circumference of 100 cm. In addition to taking medication given by doctors, he also
wants to consume omega 3 fatty acids, garlic supplements and vitamin E after reading an article.
She says that garlic supplements claim to lower blood pressure, omega-3 fatty acids have antiinflammatory properties and Vitamin E is good for the heart among other benefits.
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Learning Task
1. Are all supplements warranted in this case?
2. Why or why not?
3. What is the side effect of the supplements?
4. What is your suggestion for the patients?
13th day
ENTERAL AND PARENTERAL NUTRITION
Case
A 25 years old young man, admitted to the intensive care unit with multiple trauma due to motorbike
accident. On patient examination, it was found to have GCS 8 with respiratory depression. The
patient was normotensive 130/80 but tachycardic (118 beats per minute). Abdomen was not
distended and bowel sounds were present. A nasogastric tube was placed with a return of 200 mL
of clear gastric juice. A left femoral fracture and multiple superficial contusion were noted with no
evidence of external bleeding. The patient was placed on a ventilator and resucitated.
Laboratory data
Abdominal series : Nasogastric tube in stomach, no bowel distension, no ileus.
Chest radiography : without abnormalities
Extremity rontgen : left femoral fracture
CT scan of head : cerebral edema without intracranial hematoma
Body composition
Height : 183 cm
Actual body weight : 85 kg
Learning Task
a. What is the preferred route of access for nutritional intervention, if the gut is intact and
functional?
b. How can you prevent tube feeding complications?
Self Assessment
1. Describe benefits of enteral feeding for gastrointestinal physiology and function!
2. Describe indication and contraindication for nasoenteric tube placement!
3. Figure out common sites of inserting Central Venous Access!
4. What is main indication for parenteral nutrition
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ABSTRACTS
INTRODUCTION of THE THEME
Abstract
Indonesia recently is in transition of epidemiologic periode. Its mean that Indonesia has both
nutrition problem, undernutrition as well as overnutrition. Decreasing in undernutrition problem
(protein energy malnutrition, nutrition anemia, vitamin A deficiency, iodine deficiency) and infectious
diseases, coincindence with increasing prevalence of overnutrition and degenerative disease (type
2 of diabetes, heart disease, hypertension, gout, osteoporosis, cancer, etc). Its has been known that
nutrition is closely related to disease entity mainly infectious and degenerative diseases.
Appropriate nutrition intervention is needed for successful treatment of the diseases. The medical
nutrition therapy should be individualized by providing optimal nutrition therapy to optimized the
nutrient availability, absorption, transportation, utilization and its effects. To meet the optimal
nutrition therapy, the student need a broad knowledge about :
1. The function of nutrient and its influence to health and diseases and the food sources
2. Principle of well balanced diet and menu planning
3. Simple nutritional assessment (Dietary, anthropometric, biochemical and clinical sign)
4. Pathophysiology of nutritional deficiencies and excess
5. Concept of medical nutrition therapy (MNT)
In hospital based, medical nutrition therapy is part of health care team, consist of physician incharge
and nutrition team. Nutritrition team are consist of medical/clinical nutrition specialist, dietitian,
nurse, and include patient and family.
At the end of this study, the student is expected to know the role of optimal nutrition in healing of
diseases and promoting health
PRIMARY PROTEIN and ENERGY MALNUTRITION
Abstract
Carbohydrate as sourches of energy for human bodies. Human bodies need adequate
amount of energy daily to promote and maintain optimal health. There are several type of
carbohydrate both refine and nonrefine that compose daily product widely spread include in
Indonesia. It has been known that refine carbohydrate is related to degenerative diseases which are
increasing in the last decade. So, increasing intake of non-refined or whole grain carbohydrate
sources give a protective effect to the degenerative diseses. Other type of carbohydrate has been
identified has protective effect for health namely low and high glycemic index of carbohydrate.
Fat as sourches of energy more efficiently than carbohydrate. Fat has benefit and bad effect
to health according to fatty acid containing in food (meat, fish, grain and others). So an adequate fat
intake and appropriate ratio of saturated and unsaturated fatty acid is play a role in promoting and
maintaining optimal health.
Protein as a body building is important to maintain optimal biologic function of cells (growth,
regeneration, reproduction, etc) to promote and maintain optimal health. To achieve optimal health,
good quality of protein intake of animal sources should be consumed in adequate amount daily.
Objectives
At the end of this session, student must be able to
1. Describe the type, function and sources of carbohydrate, as well as its effect to health.
2 . Describe the type, functionand sources of protein as well as the effect to human health.
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SECONDARY PROTEIN and ENERGY MALNUTRITION
Abstract
PEM is a condition due to lack or deficit intake of carbohydrates, lipids, and protein from diet. These
conditions signed by mobilized or oxidized all of energy source in the body. The impacts of
mobilized energy are reduce body weight (fat, and muscle mass), reduce metabolic rate.
Natural history of disorder innisiated by light, moderate and the last severe PAM. Light and
moderate PEM could usually handled significantly by nutrition support. Severe PEM always followed
by clinical complication with followed by some diseases, so the management of the condition should
be need hospitalized beside nutrition care.
PEM in child bearing period could disturb growth and development. In adult PEM decreased health
status, and risks to suffer from some both communicable and non-communicable diseases.
VITAMINS DEFICIENCY
Abstract
Nutrients in food are grouped into two major group i.e. macro and micro nutrients. Macronutrients
comprise of substances that give energy such as carbohydrate, protein and fat, while micronutrients
comprise of vitamins and minerals. The human requirement for micronutrient is not as big as
macronutrient even some minerals, the requirement is very small but though they are very essential
as the human body can not produce it except vitamin D, and shall be accordingly included in the
human food.
Vitamins, according to its solubility, are classified into two very distinctive groups: fat soluble
and water soluble. This separation is also made in consider to its effect on human body and
metabolism even though they are working together in carrying out body function. Human will not be
deficient in fat soluble vitamin i.e. vitamin A, D, E, and K, unless they are on fat free diet for a
longtime, because fat is the main resources for fat soluble vitamins. In addition most fat soluble
vitamins are stored in human body or organ, even vitamin D is produced by our body using the food
we eat and helped by the ultraviolet from the sun. Unlike the fat soluble, the water soluble vitamins
are not stored and always excreted out after being used through sweat, urine and stools, therefore
human needs to intake it daily from their food. Some foods content previtamin in which the body will
transform it into vitamin when it is ingested.
Vitamin works specifically in human function. Though they have multiple roles and action in
the human body, they are working independently but cooperatively with other nutrient to support
body/organ function and because they are very specific their presence can not be substitute by
others.
Objective
At the end of the study, the student is expected able to describe the type, funtions, effect to human
health and food sources of each vitamin
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MINERALS DEFICIENCY
Abstract
Likewise vitamin, minerals also classified into two or even three group: major, trace element and
some trace which the essentialities are unclear. The classification is made base on the amount
needed by human body, while the major mineral requirement shall be equal or above 100 mg/day,
the trace elements are below 100 mg. Major mineral comprise of Calcium (Ca), Sodium (Na),
Potassium (K), Phosphorus (P), Chloride (Cl), Sulfur (S). The trace element are Iron (Fe), Iodine (I),
Zinc (Zn), Copper (Cu), Manganese (Mn), Chromium (Cr), Cobalt (Co), Selenium (Se), Molybdenum
(Mo), and Fluoride (F); and the unclear trace elements include Silicon (Si), Vanadium (V), Tin (Sn),
Nickel (Ni), Cadmium (Cd), Arsenic (As), Aluminum (Al), Boron (B)
There are some similarities between mineral and vitamins. The essentiality, unique role,
interactions and its impact to chronic diseases are similar between mineral and vitamins but the
structure, absorption (mode of absorption), classification, roles in the body, the amount needed and
the stability are different.
Objective
At the end of the study, the student is expected able to :
1. Describe the funtions and effect to human health and food sources of each mineral
2. Explain the factors that influence the availability of mineral
WELL BALANCE DIET AND MENU PLANNING
Abstract
Balanced diet is important in promoting health. Balanced diet is planned to replace in and balance
to the daily energy expended. Balanced diet consist of all nutrient in adequate amount to fullfil
person need. Factor determine energy expenditure are : age, sex, physical activity, special
condition, temperature, illness, etc.
To plan balance diet, several steps should follows :
1. Decide total energy requirement (energy expenditure) of individual or patients
2. Decide the composition of macronutrient appropriate for balanced diet
3. Use food composition table, food exchange list or nutrisurvei to translate energy required
into daily food needed appropriate to balance diet.
4. Split daily foodstuff into 3 main menu (breakfast, lunch, and dinner) and 2 snack portion
Objective
At the end of the study, the sutend is expected :
1. Undertnad the concept of balanced diet and menu planning
2. Able to use food composition table or nutrsurvey package
3. Able to analyses nutrient content of diet by using food composition table or nutri-survei
Indonesia
4. Able to plan menu appropriate to balance diet
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INFANT AND CHILDREN FEEDING PRACTICE
Abstract
Malnutrition is still high, especially in developing countries, such as Indonesia. Malnutrition has been
responsible for two-thirds of death annually among children under five. Well over two-third of these
deaths are associated with inappropriate feeding practices, mainly during the first year of life.
Inappropriate feeding practices including low prevalence of exclusive breastfeeding, too early or too
late beginning of complementary feeding, and nutritionally inadequate and unsafe of complementary
foods. Malnourished children who survive are more frequently sick and suffer the life-long
consequences of impaired development.
Objective
At the end of the study, the student is expected to be able to describe the feeding practices
in infants and young children.
NUTRITION MANAGEMENT FOR DISLIPIDAEMIA AND HIPERURECEMIA
Abstract
Dyslipidemia is condition of abnormality of blood lipid profile concentration. Lipid profile such
as triglycerides, LDL-cholesterol usually higher, and HDL-cholesterol lower than normal condition.
This condition usually due to the imbalance of diet, especially excess of carbohydrate and saturated
fat.
Usually, the disorder occurs in person with obesity. Diet management such as decreased
carbohydrate and saturated fat diet. Diet contain omega 3-poly unsaturated fatty (n-3 PUFA), often
use to normalized blood lipid concentration.
Hyperuricemia, the condition increased blood uric acid concentration above the normal level.
Uric acid is metabolic product of nucleic acid (purine, pyrimidine), that construct DNA. Hyperucemia
could caused by lack metabolism of uric acid due to enzyme deficient, and or too much purine
intake from the diet.
OBESITY AND WEIGHT MANAGEMENT
Abstract
Recently obesity is counted as a disease which attack human body systematically. It is
predominantly caused by over eating and less out put. However there are plenty of risk factors can
influence or even support this situation.
As it is said as a systemic disease, if it is not treated well, it can underly several kind of diseases
especially non contagious disease. Even the qonsequence of having obesity, when the patient got a
disease, it can perform more severe compare to non obese patient.
Weight manajement shall be perform to obese patient with or without comorbid of any related
disease.
Objectives
At the end of this session, student is able to:
1. Define obesity by using several kind of measurement
2. Explain the risk factors of overweight and obesity
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3. Describe other kind of diseases where obesity is the underlying factor
4. Describe methods that usually used to reduce or manage weight
NUTRITION AND LIFE CYCLE
Abstract
Nutrition is important to health and wellness throughout ones lifespan. Knowledge of changing
nutritional requirements is important to deliver quality health care. The student will develop a diet
plan for individuals in various life stages. All healthy people need the same nutrients during each life
stage, just in different amounts. Infancy – Birth to one year; Childhood – one year to puberty;
Adolescence – puberty to adulthood; Adulthood – last from adolescence to old age; and specially
condition are Pregnancy and Lactation.
Objective
At the end of the study, the student is expected able to describe the characteristic of each life stage
and nutrients requirement.
MEDICAL NUTRITION THERAPY
Abstract
Medical nutrition therapy refers to specific nutrition procedure including assessment and intervention
in the treatment of an illness, injury and disease condition. Medical nutrition therapy procedures
define the level, content and frequency of nutrition service that are appropriate for optimal care and
nutrition outcome. There are many component to medical nutrition therapy. Screening may be
completed by a registered dietitian (RD), dietetic technician registered (DTR) or health care
professional. Nutritional care process include assessment,establishment of client’s selfmanagement
goals, development of a nutrtion plan, documentation, communication with the primary care
provider, evaluation and reassessment and outcome measurements.
Objectives
At the end of the study, the medical student is expected to
1. Comprehend the step of medical nutrition therapy
2. Comprehend the medical nutritional care team is work together to promote patient healing
and health.
FOOD SUPPLEMENT (FUNCTIONAL FOOD/ANTIOXIDANT)
Abstract
Most people nowadays are aware that deficiency diseases can be cured, and that adequate
intakes of essential nutrients can be assured either by taking purified nutrients as supplements or in
fortified foods. By analogy, perhaps some of the benefits of a modern recommended diet could be
obtained by taking supplements that contain the active ingredients of foods that may help to prevent
diseases such as cancer, heart disease and osteoporosis. This would allow us to eat our preferred
‘unhealthy’ fat- and sugar-rich diet but still enjoy at least some of the health benefits of eating a
more prudent diet.
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Dietary supplements could include food preparations designed to meet all or part of the
nutritional and energy needs of invalids, sports drinks, slimming foods and hundreds of herbal
medicines that can be marketed as dietary supplements. The term functional foods could include
every fortified food and every food for which some sort of health claim has been made, such as
most breakfast cereals.
A few of the substances used as dietary supplements are also licensed medicines: some
generic vitamins (vitamins A and D, folic acid and cyanocobalamin, vitamin B12); a multi-vitamin
preparation designed to meet the needs of children; a fish oil preparation; and an iron and folic acid
supplement intended for pregnant women. It is permissible to make medicinal claims for these
products, for example that a fish oil preparation, lowers raised plasma triacylglycerols and so helps
to prevent heart attacks and pancreatitis. Other fish oil preparations marketed as dietary
supplements are not allowed to make such claims. Similarly, it is permissible to refer to an iron and
folic acid supplement intended for pregnant women’s role in reducing the risk of babies being born
with a neural tube defect but such claims are not allowed for other dietary supplements that contain
folic acid.
To get a medicine licensed can take up to a decade and cost many millions of pounds; this is
why many manufacturers of nutrients, ‘natural substances’ and herbal preparations choose to
market them as dietary supplements instead. This means that they are subject to legal regulations
relating to food rather than to medicines. Anything which is taken orally and not classified as a
medicine is, by default, classified as food. This has major commercial advantages for the
manufacturer who not only bypasses the expensive and slow process of getting the product
licensed but is also subject to the much less stringent legal regulations relating to food. It is illegal to
sell food which is harmful to health and it is illegal to dishonestly describe or advertise a food. This
means that although it is illegal to make false health claims for a dietary supplement it is the
prosecution that must ‘prove’ a claim to be false, whereas a medicine must be shown to be safe and
effective before it is licensed.
People take supplements for a variety of reasons, such as to compensate for a perceived or
potential inadequacy in the diet, to compensate for some perceived increase in need or defective
handling of a nutrient, to treat or prevent non-deficiency diseases or to improve athletic
performance. In many cases it is difficult to give a definitive answer or even a fairly confident answer
to the question of whether supplements or functional foods are actually effective (or even safe).
When assessing the effectiveness of a dietary supplement or functional food one must decide what
measure or measures are to be used as indicators of success or failure. In some cases, one can
monitor the effect of a supplement on the signs and or symptoms of a disease. Thus when dietary
deficiency diseases were first being identified, one could confirm the beneficial effects of a vitamin
or mineral by testing the effect upon symptoms and disease progression of purified supplements or
foods rich in the nutrient.
ENTERAL and PARENTERAL FEEDING
Abstract
Increase case admitted to the intensive care unit in uncocius condition need proper medical nutrition
therapy to prevent undernutrition. For this condition the MNT route is enteral and/or parentral is
prefered. For appropriate dicission the indication, energy and nutrient needed, choosing formula,
route of nutrtional intervention shuld be considered.
At the end of the study, student is expected to know the indication, benefit or risk each feeding
formula and the complicatiom of eneteral and parentral feeding
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REFFERENCE
1. Halsted, C.H., 1992. Toward standardized training of physicians in clinical nutrition. Am J
Clin Nutr; 56: 1-3
2. WHO, 2003. Diet nutrition and the prevention of chronic diseases. WHO tecnicval series
Report. 916
3. William, S.W. and Schelenker, E. D., 2003. Nutrion and Health. Essential of Nutrition & Diet
Therapy. 8th ed , Mosby, St Louis, Missouri,p 4-21; 45-214; 373-388; 408-434
4. Dinarto M., 2002. Tim Nutrisi, Gizi Medik Indonesia, 1: 7-8
5. Torun B. and Chew F., 1981. Protein Energy Malnutrition. In R, E. Berhman and R.M
Kliegman., editors, Nelson Essential of Pediatrics.4th ed..Toronto; pp.983-988
6. Ross A.,C. 1981. Vitamin A and retginoids. In R, E. Berhman and R.M Kliegman., editors,
Nelson Essential of Pediatrics.4th ed..Toronto; pp 306-324
7. Pronsky Z.M., and Crowe J.P., 2008., AssessmentFood-Drug Interaction. In Krause’s Food
Nutrition Therapy. Ed. Mahan L.K., and Escott-Stump S., WB. Saunders., pp.432-452
8. Hathcock J.N., Rader J.L, 1999. Food Additives, contaminants, and Natural Toxins. In
Modern Nutrition in Health and Disease, 9th ed. Williams & Wilkins, Baltimore. pp1837-1856
9. DEPKES RI, 2002. Pedoman umum Gizi Seimbang (PUGS)
10. WHO-Unicef, 2003, Global Strategy for Infant and Child Feeding, WHO Geneva
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~ CURRICULUM MAP ~
Smstr
Program or curriculum blocks
10
Senior Clerkship
9
Senior Clerkship
8
Senior clerkship
7
Medical
Emergency
(3 weeks)
Special Topic:
-Travel medicine
(2 weeks)
Elective Study III
(6 weeks)
Clinic Orientation
(Clerkship)
(6 weeks)
6
BCS (1 weeks)
The Respiratory
System and
Disorders
(4 weeks)
The
Cardiovascular
System and
Disorders
(4 weeks)
The Urinary
System and
Disorders
(3 weeks)
The Reproductive
System and
Disorders
(3 weeks)
BCS (1 weeks)
Alimentary
& hepatobiliary systems
& disorders
(4 Weeks)
BCS (1 weeks)
The Endocrine
System,
Metabolism and
Disorders
(4 weeks)
BCS (1 weeks)
Clinical Nutrition
and Disorders
(2 weeks)
BCS (1 weeks)
BCS (1 weeks)
Musculoskeletal
system &
connective
tissue disorders
(4 weeks)
Neuroscience
and
neurological
disorders
(4 weeks)
Behavior Change
and disorders
(4 weeks)
BCS (1 weeks)
Hematologic
system & disorders & clinical
oncology
(4 weeks)
BCS (1 weeks)
Immune
system &
disorders
(2 weeks)
BCS(1 weeks)
Infection
& infectious
diseases
(5 weeks)
BCS
(1 weeks)
The skin & hearing
system
& disorders
(3 weeks)
BCS (1 weeks)
Medical
Professionalism
(2 weeks)
BCS(1 weeks)
Evidence-based
Medical Practice
(2 weeks)
BCS (1 weeks)
Health Systembased Practice
(3 weeks)
BCS(1 weeks)
Community-based
practice
(4 weeks)
-
BCS (1 weeks)
Studium
Generale and
Humaniora
(3 weeks)
Medical
communication
(3 weeks)
BCS (1 weeks)
The cell
as biochemical machinery
(3 weeks)
Growth
&
development
(4 weeks)
BCS (1 weeks)
BCS(1 weeks)
BCS: (1 weeks)
BCS (1 weeks)
Elective Study
II
(1 weeks)
5
4
3
2
1
BCS (1 weeks)
Special Topic :
- Palliative
medicine
-Compleme
ntary &
Alternative
Medicine
- Forensic
(3 weeks)
Elective
Study II
(1 weeks)
Special Topic
- Ergonomi
- Geriatri
(2 weeks)
Elective
Study I
(2 weeks)
The Visual
system &
disorders
(2 weeks)
Pendidikan Pancasila & Kewarganegaraan (3 weeks)
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