RU2550078C1 - Method of determining individual upper boundary of person's requirement of macronutrients and energy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine and can be used for the selection of individual diet therapy in treatment-and-prophylactic institutions. For this purpose a patient keeps a diary of physical activity for 7 days with the registration of the passive and active time of the day t_act, t_pas. After that, an averaged coefficient of physical activity CPA_av and an average value of energy consumption E_cpaav for a day are determined. Load testing is carried out in the mode of the step-by-step increasing load with 10 W growth step, 3 minute long step duration, with the maximal load value not exceeding 100 W. Then, a graph showing the dependence of energy consumption on the load value is built and the load value, corresponding to E_cpaav, is determined, at the level of which values of nutrient exchange indices in the process of load testing V_Pcpaav, V_Ccpaav, V_Fcpaav are fixed and taking into account factual indices of nutrients V_Pres,V_Cres,V_Fres and energy consumption at rest E_res, an individual upper boundary of the patient's requirements is determined by formulas: E_ind=k₁E_res+k₂E_cpaav, V_Pind=V_Presk₁+V_Pcpaavk2, V_Cind=V_Cresk₁+V_Ccpaavk2, V_Find=V_Fresk₁+V_Fcpaavk2, where E_ind is the individual index of the person's rational energy exchange (kkal/day); E_res is energy consumption at rest (kkal/day); E_cpaav is the average value of energy consumption under physical load (kkal/day); t_act, t_pas are active and passive time of the day (hour); k₁=t_pas/24 is the coefficient of the passive time of the day; k₂=t_act/24 is the coefficient of the active time of the day; V_Pind, V_Cind, V_Find are individual indices of the nutrient exchange of the person's proteins, carbohydrates and fats (kkal/day); V_Pres, V_Cres, V_Fres are indices of the nutrient exchange of proteins, carbohydrates and fats in the rest state (kkal/day); V_Pcpaav, V_Ccpaav, V_Fcpaav are average indices of the nutrient exchange of proteins, carbohydrates and fats under physical load (kkal/day).

EFFECT: method provides the possibility of evaluating the individual indices of an upper boundary of the person's energy and macronutrient exchange with great accuracy due to the elaboration of a special system of load testing, connected with respiratory calorimetry, making it possible to obtain values of the real day-average requirement of proteins, fats, carbohydrates and energy.

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Description

The invention relates to medicine and can be used to select individual diet therapy in medical institutions.

Nutrition is an integral part of human life and one of the most important factors affecting health. Currently, specialized diets have been developed to treat a wide variety of diseases. However, the problem is that the currently developed diets are focused solely on the pathogenetic effect of the nutrition factor, the average age-related needs of patients for nutrients and energy, and practically do not take into account the individual needs of the patient, which dramatically reduces the effectiveness of diet therapy. The doctor’s lack of objective information about the patient’s actual needs for energy and macronutrients leads to frequent therapeutic errors. The appointment of a depersonalized diet in this case causes objective harm to the patient in the form of pathological metabolic shifts and adverse (and often irreversible) changes in quantitative indicators of body composition, aggravation of the clinical course of diseases and worsening prognosis.

In addition, any diet therapy requires constant correction of the treatment, depending on the dynamics of the patient’s clinical status, treatment effectiveness, phase of the disease, which should also be controlled by objective indicators of metabolism and energy.

Thus, the need for an objective study of the patient’s actual needs for substances and energy for individualizing diet therapy and instrumental monitoring of its effectiveness is beyond doubt.

Taking into account the patient’s individual needs for macronutrients and energy implies determining the optimal range (lower and upper bounds) of the patient’s personal needs for macronutrients and energy - the so-called “individual metabolic corridor”. At the same time, the lower boundary of the indicated corridor should serve as indicators of energy expenditure and oxidation rates of macronutrients in the state of basic metabolism, and the upper limit - the same indicators with the average physical activity of the patient during the day.

At present, the method of indirect respiratory rest calorimetry is known, which makes it possible to estimate the energy expenditures and the oxidation rates of the main food substances in the state of basic metabolism [Human Physiology: textbook (in two volumes. T.2) ./ Ed. V.M. Pokrovsky, G.F. Korotko. - M .: Medicine, 2002. - S. 106-122]. The method is based on measuring the amount of oxygen absorbed and carbon dioxide released and further converting the measured parameters by formulas into indicators of energy costs and oxidation of macronutrients.

The disadvantage of this method is that it is incomplete and can characterize only the minimum human needs for nutrients and energy, that is, the lower limit. The upper limit of needs is determined by its everyday physical activity and is certainly higher than that determined during the study of basic metabolism. Thus, the study of basic metabolism provides information only on a part of a person’s true needs - determines his minimum needs for macronutrients and energy.

The definition of the upper boundary of the “individual metabolic corridor” is no less important, since it allows you to calculate the maximum allowable values of calorie content and macronutrient content in the diet of patients with heart failure. An objective method for determining these indicators has not yet been developed.

Closest to the proposed is a method for determining the individual upper limit of human needs for macronutrients and energy, including the study of metabolic characteristics at rest and during stress testing, determining the coefficient of physical activity based on the calculation of the coefficient of physical activity according to tabular data depending on the patient’s labor group [ Martinchik A.N., Mayev I.V., Petukhov A.B. Human nutrition (basics of nutrition). - M., 2002. - S. 101-102].

The disadvantage of this method is its low accuracy in calculating energy needs, due to the fact that the known tabular data on the increase in energy consumption when performing a particular physical work is significantly averaged. In addition, the method does not allow to evaluate the rate of oxidation of food substances during exercise, which in turn does not allow to determine the optimal range of protein, fat and carbohydrate content in the diet.

The objective of the invention is to develop a method that allows with high accuracy to evaluate individual indicators of the upper limit of energy and macronutrient metabolism of a person by developing a special system of stress testing associated with respiratory calorimetry, which allows to obtain the actual average daily requirements for proteins, fats, carbohydrates and energy.

This problem is solved in that in the method for determining the individual upper limit of human needs for macronutrients and energy, including the study of metabolic characteristics at rest and during stress testing, determination of the coefficient of physical activity, it is proposed that the patient keep a diary of a profile of physical activity with time recording for 7 days passive and active time of day t _act , t _pass. Given this time, determine the average coefficient of physical activity CFA _cf and the average value of energy _expenditure E _kfasr per day. Conduct load testing in a stepwise increasing load mode with an increment of 10 W, with a stage duration of 3 minutes, with the maximum load not exceeding 100 W. Then, build a graph of the dependence of energy consumption on the load and determine the load value corresponding to E _kfasr , at the level of which to fix the values of nutrient metabolism during stress testing V _Bkfasr , V _Ukfasr , V _Zhkfasr and taking into account the actual indicators of nutrients V _Bpok , V _Upok , V _Zhpok and energy _expenditure alone E _pok , to determine the individual upper limit of the patient's needs for energy, proteins, fats and carbohydrates, i.e. macronutrients, according to the formulas:

where E _ind - individual upper limit of the patient's needs for energy, (kcal / day);

E _pok - energy consumption at rest, (kcal / day);

E _kfasr - the average value of energy _consumption during exercise (kcal / day);

t _act , t _pass - active and passive time of day (hour);

k ₁ = t _pass / 24 - passive time coefficient per day,

k ₂ = t _act / 24 - coefficient of active time per day,

V _Bind , V _Wind , V _Zhind - individual upper limits of the patient's needs for proteins, fats and carbohydrates, (kcal / day);

V _Side , V _side , V _side - indicators of nutrient metabolism of proteins, carbohydrates and fats at rest, (kcal / day);

V _Bkfasr , V _Ukfasr , V _Zhkfasr - average indicators of nutrient metabolism of proteins, carbohydrates and fats during exercise, (kcal / day);

A significant advantage of the method is the good tolerance of testing even for patients with low exercise tolerance, which is associated with a low intensity of the load. This allows you to use the technique in the examination of patients even with severe cardiovascular pathology.

Figure 1 presents a graph of the energy expenditure of patient K. (example) at a metered load; figure 2 - coefficient of physical activity at different stages of stress testing; figure 3 - oxidation of carbohydrates in patient K. at a metered load; figure 4 - fat oxidation in patient K. at a metered load; figure 5 - protein oxidation in patient K. at a metered load.

The method is carried out in several stages.

- Studying the profile of everyday physical activity, calculating the proportion (shares) of active and passive time of day, as well as the average coefficient of physical activity per day.

- The study of metabolic characteristics in conditions of basic metabolism using the method of respiratory calorimetry.

- Study of metabolic characteristics during exercise using the method of respiratory calorimetry during stress testing.

- Calculation of actual energy expenditures and oxidative loss of nutrients during the day, taking into account the duration of wakefulness and sleep, the degree of physical activity, metabolic activity in the state of basic metabolism and during physical activity.

The study of the profile of physical activity is carried out using the method of maintaining a diary of physical activity. The patient leads a familiar lifestyle for 7 days and fills out a diary. Then, the average duration of passive time (sleep and rest) (t _pass ) and active time of day (t _act, ) is determined from the diary.

In this case, the well-known division of physical activity into 6 groups according to labor intensity is used: I - sleep, II - rest, III - light work, IV - moderate work, V - hard work, VI - very hard work, use classical tables and determine the time t _i for each type of load. For each group, the average duration of work is recorded during the day and, using the known values of the physical activity coefficient for each intensity group, the average physical activity coefficient (CFA _cf ) is calculated by the formula:

where CFA _cf - average coefficient of physical activity, CFA _i - CFA values for a given type of physical work, t _i - time of this physical work.

This parameter is used in further calculations.

Then determine the average value of energy E _kfasr = CFA _cf. · E _pok.

The study of basic metabolism:

During the day, the patient collects daily urine for subsequent determination of daily urea. Using the value of daily urea, residual nitrogen is calculated by the formula:

Where N is the residual nitrogen (g / day), M is the daily urea (g / day), V is the volume of daily urine (l).

The found value of residual nitrogen for this patient is entered into the device before the study for further automatic calculation of daily protein loss.

On the eve of the study, preliminary instruction and trial modeling of the upcoming study are carried out to level the stress situation during the measurement. The patient is recommended the last meal 8-10 hours before the study.

The study uses a stationary metabolograph using a dilution helmet or respiratory mask.

The oxygen consumption and carbon dioxide emissions are measured using calorimetry to further calculate energy expenditures, oxidation rates of proteins, fats and carbohydrates at rest: V _Bpok , V _Upok , V _Zhpok . At the same time, the recorded parameters are standardized by temperature, barometric pressure and humidity in accordance with the international standardization protocol STPD.

Exercise calorimetry:

To study the metabolic parameters during exercise, mobile metabolographs are used. The patient performs a test with a stepwise increasing load. In this case, a protocol is used with a small increment in load increment (10 W) and a duration of steps equal to 3 minutes; the maximum load should not exceed 100 W. This study protocol allows all patients to isolate the period in which CFA reaches the level found earlier than the average daily CFA _cf. . At this load level, the average values of V _Bkfasr , V _Ukfasr , V _Zhkfasr , and oxidation rates are _recorded . Knowing the basal metabolic rate (V _Bpok , V _Upok , V _Zhpook , E _pok ), determine the individual upper limits of energy and macronutrient requirements according to the above formulas.

Examinations are carried out before treatment, as well as during diet therapy to monitor changes in metabolic parameters and evaluate the effectiveness of treatment.

Thus, a comprehensive study of the parameters of energy and nutrient metabolism can be applied in clinical practice during the dietetic treatment of patients for the selection of individual diet therapy and greatly facilitates specialist decision-making on changing the course of treatment.

Example 1

Patient K., was admitted to the department of cardiovascular pathology with a diagnosis of coronary heart disease, angina pectoris 2 functional class body weight equal to 121 kg with a height of 173 cm. The calculation steps are commented below:

Drawing up a profile of physical activity (patient filling out a diary within 7 days). It can be seen from the diary that the patient has significant limitations in physical activity. Inactive time of day at which the energy consumption close to the energy expenditure BMR _pass occupy about t = 20 h (k ₁ = 20/24 = 0.83). Physical activity accounts for only t _act = 4 hours (k ₂ = 4/24 = 0.17), of which 3 hours are light work and 1 hour is moderate work, the patient does not perform hard physical work.

At the second stage, the averaged coefficient of physical activity per day was calculated using formula 1. In this case, CFA _cf was 2.25.

In the third stage, in the study of daily urea, a value of M = 482.2 mmol / L was obtained, with V = 1.2 L. Then, according to the obtained data, residual nitrogen was determined; its value was N = 16.208 g / day.

Further, according to the well-known formula, the value of the protein oxidation rate in the state of the main metabolism was _obtained : V _Bpoc = 6.25 · N = 6.25 · 16.208 = 101 g / day.

The well-known formulas also determined the values of energy consumption and the oxidation rate of carbohydrates and fats at rest, which amounted to:

E _pok = 2306 kcal / day;

V _Pack, = 241 g / day;

V _Zhpok = 104 g / day.

Exercise testing was carried out using the CORTEX BiophysikMetaMax® 3В portable CPX system metaboloboph (CORTEX, Germany) complete with a treadmill. At the 4th step of the load, energy expenditures E _{kfa cf} = 7657 kcal / day were fixed (see figure 1), in which CFA = CFA _cf = 3.25 (see figure 2).

At this stage, the following values were determined for the rates of oxidation of nutrients (see figures 3-5):

V _{B kfa cf} = 144 g / day.

V _{At kfa avg,} = 1530 g / day;

V _{W kfa cf.} = 107 g / cit.

The obtained values of energy expenditures and oxidation rates of nutrients are multiplied by the corresponding number of hours spent per day and the actual values per day are obtained in the state of basic metabolism and with an average daily physical load. These values were:

E _pok ∗ k ₁ = 2306 ∗ 0.83 = 1913 kcal / day

V _Bpok * k ₁ = 101 ∗ 0.83 = 83.8 g / day.

V _Pack * k ₁ = 241 * 0.83 = 200 g / day.

V _Zhpok ∗ k ₁ = 104 ∗ 0.83 = 86.3 g / day.

E _kfasr ∗ k ₂ = 7657 ∗ 0.17 = 1301 kcal / day

V _{B kfa cf} ∗ k ₂ = 144 ∗ 0.17 = 24.5 g / day.

V _{In kfa kp} ∗ k ₂ = 1530 ∗ 0.17 = 260 g / day.

V _{W kfa cf} ∗ k ₂ , = 107 ∗ 0.17 = 18.2 g / day.

Summing up these indicators, the total average daily energy expenditures and oxidation rates of proteins of fats and carbohydrates are obtained:

E _ind = k ₁ E _pok + k ₂ E _{kfa cf} = 1913 + 1301 = 3214 kcal / day.

V _{B ind} = V _Bp k ₁ + _{B B kfa cf} k ₂ = 83.8 + 24.5 = 108.3 g / day.

V _{U ind} = V _Upok k ₁ + V _{U kfa cf} k ₂ = 200 + 260 = 460 g / day.

V _{W ind} = V _{L kok 1} + V _{W kfa cf} k ₂ = 86.3 + 18.2 = 104.5 g / day.

Thus, the needs of the patient, and therefore the optimal characteristics ("metabolic corridor") of the diet of patient K. can be represented as follows: energy value should be in the range 2306-3214 kcal / day .; protein content - 101-108.3 g / day .; fat content - 86.3-104.5 g / day .; carbohydrate content - 200-260 g / day.

The result of this invention is the ability to select adequate diet therapy, focused on the objective individual needs of the patient. The method allows to evaluate the effectiveness of diet therapy under the control of objective research methods, thereby eliminating the subjective factor, according to the data obtained, it is possible to judge more accurately the susceptibility of the patient's body to the prescribed diet.

The method can be widely used to study the characteristics of metabolic processes and the need for nutrients and energy in patients with a wide profile and serve as the basis for developing recommendations for therapeutic and preventive nutrition of patients. As a result, this technique allows you to select the optimal diet management scheme for patients, while preventing the development of possible complications of unbalanced diet therapy.

The described method was tested during the examination and treatment of 430 patients (174 men and 256 women) aged 20 to 79 years with a cardiological pathology that developed against the background of a long course of obesity, which made it possible to develop individual diets for each patient, as well as recommendations for this patient population. The study was carried out on the basis of the cardiovascular pathology department of the Research Institute of Nutrition RAMS RAMS, using the CORTEX BiophysikMetaMax® 3В portable CPX system metabolic process (CORTEX, Germany); the data were processed using the CORTEX BiophysikMetaSoft® CPX testingsoftware software (CORTEX, Germany).

On the basis of the proposed method for determining the individual range of needs for macronutrients and energy of patients, personification of patient diet was carried out, which made it possible to significantly reduce the clinical manifestations of the disease, reduce effective doses of drugs, improve the quality of life of patients.

Claims (1)

A method for determining the individual upper limit of human needs for macronutrients and energy, including the study of metabolic characteristics at rest and during stress testing, determining the coefficient of physical activity, characterized in that the patient maintains a diary of a profile of physical activity for 7 days with registration of passive and active time of day t _act , t _pac. , taking into account this time, determine the average coefficient of physical activity of CFA _cf and the average value of energy consumption E _kfasr per day, and load testing is carried out in the mode of stepwise increasing load with increment of 10 W, duration of steps equal to 3 minutes, while the maximum load should not exceed 100 W, then build a graph of the dependence of energy consumption on the load and determine the value of the load corresponding to E _kfasr , at the level of which the values of nutrient indicators exchange during stress testing V _Bkfasr , V _Ukfasr , V _Zhkfasr and taking into account the actual indicators of nutrients V _Bpok , V _Upok , V _Zhpok and energy _expenditures at rest E _pok , determine the individual upper limit of the patient's needs according to the formulas
E _ind = k ₁ E _pok + k ₂ E _kfasr,
V _{B ind} = V _Bpk k ₁ + V _{B kfa cf} k ₂ ,
V _{U ind} = V _Pack k ₁ + V _{U kfa cf} k ₂ ,
V _{W ind} = V _Zhpok k ₁ + V _{W kfa cf} k ₂ ,
where E _ind - an individual indicator of rational energy metabolism of a person (kcal / day);
E _pok - energy consumption at rest (kcal / day);
E _kfasr - the average value of energy consumption during physical activity (kcal / day);
t _act , t _pass - active and passive time of day (hour);
k ₁ = t _pass / 24 - passive time factor of the day;
k _{act 2} = t / 24 - active time of day index;
V _Bind , V _Wind , V _Zhind - individual indicators of nutrient metabolism of proteins, carbohydrates and human fats (kcal / day);
V _Bpok , V _Upok , V _Zhpok - indicators of nutrient metabolism of proteins, carbohydrates and fats at rest (kcal / day);
V _Bkfasr , V _Ukfasr , U _Zhkfasr - average indicators of nutrient metabolism of proteins, carbohydrates and fats during physical activity (kcal / day).

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