AuSPEN NEWSLETTER - FEBRUARY 2000

AuSPEN NEWSLETTER
Number 1 : FEBRUARY 2000

MINUTES OF THE AuSPEN ANNUAL GENERAL MEETING HELD ON FRIDAY 23rd OCTOBER 1998 AT THE NATIONAL CONVENTION CENTRE, CANBERRA.

1. Members Present :

Leanna Read Alan Spencer Dorothy Francis Penny Maclennan
Miranda Ip Narelle Hore Melvyn Davis Paul Woods
Ross Smith Patrick Ball Kris Hume Karen Kingham
Helen Pickering Andrew Thomson Bob MacMahon Elizabeth Morrell
Tony Donaghy Mark Sutherland Cathy Vlouhas Nicola Riley
Sally McCray Neil Cunningham Cathie Richards Peter Wilson
Winsome Abbott Michael Barnett Jane Luddington Marcelle Middleton
Sabita Rajeshwar Tom Hartley Liliana Sputore Maria Townsend
Ibolya Nyulasi Christine Kiddell Kerry Forbes David Russell
Julie Bines - - -

2. Apologies :

Roger White, Darrell Crawford, Kevin Williams

3. Minutes of the Previous AGM

Proposed to be accepted by Paul Woods, Seconded by Michael Barnett

4. Business Arising :

There were no comments.

5. President's Report by Julie Bines :

This year has been a very active and important year for AuSPEN. We have targetted the priorities established by the Strategic Planning Committee Meeting late in 1997. In an effort to enhance the exposure of the Society we have developed promotional material and through this joint Scientific Meeting with the Gastroenterological Society of Australia we have tried to increase exposure to the specific target groups of physicians, surgeons and nurses.

Four specific task groups or committees have been established. These are the Strategic Planning Committee, Scientific Program Committee, Professional Development Committee and the Research and Clinical Advisory Committee.

I believe that the future survival of this Society depends on the development of important strategic alliances. These alliances need to be based at a local, State basis as well as at national and international levels. The development of a solid base membership is essential. Looking to formalize alliances with New Zealand and possibly with the Asian Society (PENSA) I believe should be considered. AuSPEN has been an active vocal member of the International Confederation of Nutrition Support Organizations. This international collaboration I believe provides exciting opportunities for AuSPEN Members. The preparation of educational material by way of a structured nutrition support curriculum and a mechanism for accreditation is a major step forward for AuSPEN. Access to this information will be avaliable to AuSPEN Members as part of their subscription.

I wish to personally thank the Members of Council for their support and hard work over the year. I would like to send the Society's best wishes to Margaret Allman, (AuSPEN Secretary) and new baby Thomas. I would like to thank Sabita Rajeshwar and the members of the local Organising Committee for all the hard work that was required to achieve this excellent Conference. I would also like to acknowledge the support of the Industry who are critical to the viability of the Society.

6. Treasurer's Report.

This was presented by Paul Woods as Kevin Williams, the Treasurer, was an apology. Paul highlighted the problem of our foreign exchange exposure, which made the Society vulnerable through the Journal expenses. A vote of thanks was extended to Kevin Williams for his outstanding work as Treasurer of AuSPEN. David Russell moved that the Treasurer's Report be accepted, seconded by Tom Hartley.

7. Presentation of the 1998 Travel Grants.

There were no Awards presented. Julie Bines noted that the Society needs to advertise the availability of these Grants more widely.

8. New Members.

The following new Members already had been admitted to the Society since the last AGM.

Patrick Ball, 7/98, NZ Michael Barnett, 10/97, UK Judy Robbins, 12/97, VIC
Dianne Chaseling, 2/98, QLD Tania Engeman, 7/98, QLD Helen Shelley, 7/98, VIC
Jane Gabb, 7/98, NSW Kerryn Gamble, 5/98, VIC Timothy Spencer, 7/98, NSW
Vanessa Giannikas, 5/98, NSW Patricia Gleeson, 11/97, QLD Karen Storer, 8/98, NSW
Anne Gleeson, 12/97, VIC Eleanor Gregson, 12/97, VIC Anne-Marie Wilson, 10/98, VIC
Joerg Griesel, 2/98, NSW John Hall, 11/97, WA Deminia Yaacoub, 2/98, NSW
Ralph Heine, 7/98, VIC Clare Jennings, 7/98, VIC Kylie Shanahan, 10/98, VIC
Deborah Jessen, 10/98, VIC Zhu Ming Jiang, 7/98, China Sheena Singh, 8/98, NSW
Sujata Joshi, 7/98, VIC Linda Kar, 2/98, VIC Helen Still, 10/97, QLD
Karen Kingham, 5/98, NSW Sonya Mattiazzi, 7/98, QLD Justine Turner, 10/97, WA
Paola Parkins, 5/98, VIC Amanda Proctor, 7/98, VIC Amanda Wray, 5/98, SA
Min Zhang, 11/97, SA - -

Proposed by Ross Smith, Seconded by Mal Davis.

9. Vote of Thanks to the Retired Members of Council.

Retiring Members of Council included Kevin Williams, who was Treasurer of AuSPEN for a number of years. His dedication and excellent systematic way of organising AuSPEN's Accounts were duly recognised.

Leanna Read also retired after being on Council for 6 years. She has made a significant contribution to the scientific endeavours of AuSPEN.

10. New Council Members.

The following Members have nominated successfully for Council : Elizabeth Morrell, Maria Makrides and Liliana Sputore. Their nominations were proposed by Bob MacMahon and Seconded by Tom Hartley.

Office Bearers of the Society for 1999 will be :

President - Julie Bines, who agreed to continue her Presidency. Secretary - Liliana Sputore President Elect - Paul Woods Treasurer - Sabita Rajeshwar

11. 1998 Scientific Meeting.

It is a different concept that AuSPEN has explored in terms of sharing and running the meeting in parallel with the Gastroenterology Society of Australia. There were significant positives with this process with Elaine Siggins from the Australian Gastroenterology Society who organised both conferences simultaneously. This has had a positive effect and certainly financially we look forward to a profit from this meeting.

Trade support has also been excellent creating a synergy between the two Societies. We look forward to some feedback from both the Conference Organising Committee and from the Members as to whether the Society should pursue such a process in the future.

12. Report from the 1999 Annual Scientific Meeting.

The Convenor of the 1999 meeting will be Alan Spencer. The meeting is anticipated to be in September and possibly on the Gold Coast. Professor Jeejeebhoy has been proposed as the invited overseas speaker.

13. Votes of Thanks.

A vote of thanks was moved by Julie Bines on behalf of the Society to the Organising Committee of the 1998 Meeting, which included Sabita Rajeshwar, Margaret Allman, Marcelle Middleton, Karen Stoner and Kevin Steven.

Julie Bines moved a vote of thanks be extended to the Sustaining Associates, Seconded by Paul Woods.

14. General Business.

No reports from the Strategic Planning Group, the Scientific Programme Committee, the Research and Clinical Advisory Committee or the Professional Development Committee.

Julie Bines reported on developments with the Federation of Australian Nutrition Societies. In her report she outlined the proposed structure of this group and it was decided that AuSPEN should take a cautious approach in pursuing involvement.

The International Confederation of Nutrition Support Organisations is comprised of recognised nutrition support organisations from around the World. Julie Bines reported on their proposals. This group has met overseas in Nice and had discussions regarding developing a Web based discipline specific nutrition support curriculum. AuSPEN would be both interested and actively participating in such developments so that we can disseminate educational material to our Members. Julie Bines will continue to serve and represent AuSPEN at these Committees.

15. Motion.

This Motion was put to the AGM by Kevin Williams :

That the Council of AuSPEN investigates the mechanism by which New Zealand can become part of the Society as a region rather than by individual Membership and that this proposal be brought back to the Society as a motion at a subsequent meeting.

Julie Bines spoke to the motion that we need to extend the Society's Membership and perhaps New Zealand could be a source of new Members. AuSPEN already has a significant number of N.Z. Members. Such a move may require changing the name of the Society. It was proposed by Paul Woods that this should be explored and that the Society's name be changed to encompass New Zealand, Seconded by Dorothy Francis.

16. Permanent Secretariat.

The item of a permanent secretariat for the Society was raised and this will be finalised by the end of the year.

17. Student Membership.

Kevin Williams proposed the introduction of Student Membership. It was moved that Student Membership dues be set at $75 per annum for students who are able to verify their student status. Supported by David Russell, Seconded by Bob MacMahon.

The meeting closed at 5.30pm.


MINUTES OF THE AuSPEN ANNUAL GENERAL MEETING HELD ON
FRIDAY 22nd OCTOBER 1999 AT THE GOLD COAST INTERNATIONAL HOTEL

MEMBERS PRESENT

Sabita Rajeshwar Elisabeth Morrell Stephanie Morrison Paul Woods
Helen Pickering Winsome Abbott Penny Hillsman Julie Bines
Narelle Hore Wendy Davidson Alan Spencer Linda Kar
David Russell Joy Blacka Ibolya Nyulasi Indi Richardson
Andrew Thomson Melwyn Davis Andrew Davies Patrick Ball
Joanne Davis Ralf Hein Kathryn Marshall Liliana Sputore
Kerry Forbes Ross Smith - -

APOLOGIES:

Kevin Williams, Maria Makrides, Michael Barnett, David Forbes and Roger White.

MINUTES OF PREVIOUS AGM:

These were proposed. Accepted by S. Rajeshwar and seconded by D. Russell.

BUSINESS ARISING:

No comments.

PRESIDENT'S REPORT BY JULIE BINES.

Last year at the AGM we presented a number of priorities to achieve in 1999. I am pleased to say that many of these aims have been successfully achieved.

(1) We now have a functioning Secretariat. This will be important in maintaining continuity as a communication hub for the Society. Through the Secretariat a membership database has been developed. This will greatly improve interaction between the Society and its membership. This has been facilitated by lbolya and I am very grateful for her efforts in establishing the permanent Secretariat.

(2) The Micronutrient Guidelines have been officially launched. This document will fill an important gap in current parenteral nutrition practice in Australia. I thank David Russell for taking on the task of completing this document with the assistance of Michael Bamett and Alan Shenkin.

(3) AuSPEN has been at the forefront of the educational initiatives being developed by the ICNSO. Through this involvement we hope to have a web-based education program available to members of AuSPEN very soon.

(4)Locally AuSPEN has played a leadership role in minimising the clinical impact of the current intravenous multivitamin shortage.

Through the past year AuSPEN has been trying to reach out to other professionals in other disciplines who are interested in nutrition. While these achievements are certainly something we can all be proud of, there are still important challenges that the Society must address.

AuSPEN must continue to work hard at establishing and maintaining strategic alliances within different disease orientated societies. We need to work with Industry to bring to our patients some of the recent advancements in clinical nutrition by way of new products and treatment protocols.

I am very honoured to have been President of AuSPEN for the last 3 years.

I would like to thank

I wish Paul and the Executive all the best as they bring AuSPEN into the new millennium

TREASURER’S REPORT BY SABITA RAJESHWAR

Profit & Loss Comparison

1/1/98 through to 31/12/99 (in Aus Dollars)

Category Description 1/1/98-131/12/98 1/1/99-31/12/99
INCOME - -
Conference '97 1132.43 0.00

Conference '98

- -
B'fast Deposit 300.00 0.00
Conference '98 - Other 13950.00 0.00

Total Conference '98

14250.00 0.00
Interest 934.56 524.46
Subscriptions 20700.00 8158.25
Income - Other 0.00 13210.00
TOTAL INCOME 37016.99 21892.71





EXPENSES 1/1/98-131/12/98 1/1/99-31/12/99
Conference '98: - -
B'fast Deposit 300.00 0.00
Dinner Deposit 400.00 0.00
Float 5000.00 0.00
Total Conference '98 5700.00 0.00
Conference 0.00 5060.00
Council Meeting - -
Conferlink 694.75 1587.00
Total Council Meeting 694.75 1587.00
Equipment 0.00 701.00
Fees & Charges: - -
Auditing fees 400.00 0.00
Bank Charges 243.40 156.90
Debits Tax 0.00 6.50
Deposits Tax 0.00 4.99
Merchant Adjust 1450.00 200.00
Merchant Fee 0.00 212.50
Fees & Charges - Other 0.00 0.08
Total Fees & Charges 2093.40 580.97
Flight 0.00 2296.90
Gifts 0.00 128.30
Newsletter 6171.27 4599.15
Nutrition Jrnl. 14526.11 19497.73
Posting 248.25 116.58
Printing 0.00 1160.35
Returns 0.00 218.00
Stationery 295.00 0.00
Travel: - -
Travel Grant 3953.30 0.00
Travel - Other 0.00 18.50
Total Travel 3953.30 18.50
TOTAL EXPENSES 33682.08 35964.48
TOTAL INCOME/EXPENSE 3334.91 -14071.77

This was accepted by I. Nyulasi and seconded by H. Pickering.

PRESENTATION OF 1998 TRAVEL GRANT AWARDS

Two requests have been presented to council this year, both of which have been successful: L. Kar and K. Forbes.

MEMBERSHIP UPDATE

The current total number of financial members of the Society is 237. The following new members have been accepted by the Society since last AGM:

Nicole Tepana Dr. Geoffrey Forbes
Alison Hannam Martell Davidson
Dr. Kilminster Dr. NG
Gemma McLeod Ruth de Souza
Mrs. Ward Christine Walsh
Sandra Cork Dr. David Moore
Melinda White Joy Blacka
Joanne Clark Jodie Bennett
Roy Dennis Brigitte Coloran
Scott Parkes Andrew Davies
Anne Marie Wilson Jacqueline Bailey
Maryanne Chapmen Kylie Shanahan

NEW COUNCIL MEMBERS

The following members have been nominated for Council and have been accepted:

Andrew Thomson, Andrew Davies and Alan Spencer.

This was accepted by P. Woods and seconded by I. Nyulasi.

RETIRING COUNCIL MEMBERS:

D. Crawford, after approximately 7 years on Council.
S. Rajeshwar, after a year of serving as treasurer, as agreed when she took this role on and after a busy year of organising the 1998 Canberra Society Scientific meeting.

J. Bines proposed a vote of thanks for their significant contribution to the Society.

J. Bines is also retiring from the role of President of the Society after 3 years. She has also served as Council Member for various years previous to this. She has however agreed to stay on Council. Her contribution to the Society has been outstanding through the years.

Council has extended a vote of thanks to Julie for her role as President.

OFFICE BEARER’S FOR 2000:

Executive capacity:

Rest of Council:

ANNUAL SCIENTIFIC MEETINGS

1999/GOLD COAST
This has so far shown to be a success, demonstrated by both the attendance and the quality of the program.

2000/LORNE, VIC.
Dates: October 26-28, 2000.

2001/SYDNEY
This will be held in association with the World Congress of ICU, with one day in common of scientific program. Dates: sometime between the 28th of October and 1st of November 2001.

2002/ADELAIDE
Dates unknown at this stage.

VOTE OF THANKS

Julie Bines moved a vote of thanks on behalf of the Society, to be extended to the Conference Organising committee, with A. Spencer as convenor, D. Crawford with his major involvement with the scientific program and Charles Fleetwood as conference organiser.

A vote of thanks was also moved to the Sustaining Associates by J. Bines and seconded by P. Woods. These are:

Gold sponsors: Baxter and Novartis

Silver sponsors: Abbott and Nutritia

Bronze sponsors: Mead Jhonson and Tyco HealthCare.

Frezenius was thanked for sponsoring Dr. McFie.

Nutrition Consultants was also a sponsor.

GENERAL BUSINESS

  1. Nutrition Journal

    The inclusion of the Nutrition Journal as part of the membership fee of AuSPEN has become a difficult issue for the last 12 months.

    The increase in cost of the Journal, particularly due to currency exchange has created funding problems to the extent of chronically running the Society at a loss. The current $100.00 membership fee is insufficient to cover for running costs, Newsletter, Journal, etc.

    Fortunately, profit from last year’s scientific meeting has managed to cover for this deficit. Nevertheless it would be unwise for the Society to rely on this, as this income cannot be warranted on an ongoing basis.

    Breakdown of costs:

    Current cost of the Nutrition Journal $81.00/person/year

    Production and mailing of newsletter $32.00/person/year

    Society costs $30.00/person/year

    Total $143.00/person/year

    Current membership fee $100.00/person/year

    (Negative by $43.00 /person/year)

    I. Nyulasi presented results of the questionnaires sent out to the general membership seeking their opinion on the Journal subscription as part of the membership fee. Results reported are as follow:

    Questionnaires circulated: Approx. to 200 members

    Responses received: 60, of which:

    *80% believed that subscribing to Nutrition was an appropriate use of funds.

    *60% did not prefer subscription to another journal.

    P. Woods expressed concern re: keep running the Society at a loss. Options suggested:

    *Increase fee to $150.00 (to cover cost)

    *Keep fee at $100.00 and discontinue the inclusion of the Journal as part of the subscription fee.

    (NB: The subscription to the journal cannot be made optional to members as bulk order makes the purchase of the journal cost effective).

    A provisional motion was proposed by P. Woods with both of the above options.

    The present membership felt that it was worth making further considerations before making a decision.

    Comments made by present members:

    Action: A small task group amongst council members will be formed who will approach this issue further with the trade during this scientific meeting. If the outcome is unsuccessful by the end of this meeting, the motion will be put forward to the membership and an extraordinary AGM to be held. Vote by proxy for those members unable to attend will be considered.

  2. Newsletter/Website

    This will be a priority for this coming year. Electronic newsletter will be considered.

  3. Federation of Australian Nutrition Societies.

    Little activity has occurred in this area for the past year.

    The Web based education program is close to conclusion (Jan 2000).

    There will be a year 2000 symposium in Brisbane, which could be an opportunity for involvement for the Society, but it is uncertain if the symposium will go ahead.

  4. New Zeland issue.

    This discussion has followed last year’s idea to incorporate N.Z. as part of AuSPEN. This issue including the background, legality and implications were discussed and presented by P. Woods.

    The Society has been accepting members from N.Z. and Asian countries. N.Z. has shown strong interest in becoming associated to AuSPEN and members have expressed and demonstrated support including increasing the membership numbers.

    The current name of the Society does not include N.Z. members.

    If the name of the Society takes place, then other corporate changes will occur as well.

    Present members suggested that Council re-visits the concept and sells such concept in the actual place (eg. hold a scientific meeting in N.Z.)

    M.Davis suggested that consideration should be given to ensure that the continuation of support from the industry is still warranted in such case.

    P. Woods proposed a motion that a change of name is adopted to include the N.Z. membership.

    Action: Distribute this motion amongst members and discuss this at an extraordinary AGM to come to a decision. Members unable to attend this meeting should have access to a vote by proxy.

NEW BUSINESS - Nil.

Meeting closed at 5.55PM.

Next meeting: Friday 27/10/2000 at Lorne. Time to be advised in the Conference Program.


REPORT FROM THE 1999 ANNUAL SCIENTIFIC MEETING

Alan Spencer.

Here are the results of the feedback and evaluation forms filled out for the recent AuSPEN Conference held at the Gold Coast. Apart from a few concerns with the food, the response on the whole was very positive. I would like to take this oppotunity to thank Dr. Darrell Crawford and Mr. Charles Fleetwood for their invaluable help in organising this Conference. I wish the Victorian team the best for organising the 2000 Conference to be held in Lorne in October.

EVALUATION OF 25TH ANNUAL SCIENTIFIC MEETING OF AuSPEN, SURFERS PARADISE 22ND - 23RD OCTOBER 1999

Number of forms returned        =   32(Approximately 20% of delegates)

                            Excellent                    Satisfactory
Programme                       1         2        3           4
Content                        18        13        1           0
Quality of Presentation        21        12        1           1
Venue Facilities               22        10        0           0
Poster Layout                   8        14        8           0
Trade layout                   13        16        2           0
Catering                        7        13        9           3

Comments:

Better quality Free Papers needed (2)
International speakers were excellent (2)
Excellent program - one of the best conference been to in years (4)
More presentations from Dietitians needed
Venue was too cold
Everything excellent
Catering:  Long queues 
           Not enough for vegetarians
           Croissants - poor choice



                                  Excellent          Satisfactory
                                    1        2            3
Welcome breakfast                  13       12            3
Conference dinner                  12       13            2


Comments:

Memorable conference dinner
Tigers were great (6)
More time for dinner
Welcome breakfast was a  good idea
Food at dinner was average, but venue excellent

Highlights:

International speakers (10)
Memorable dinner (5)
Excellent program content (3)
Venue (3)
Tigers (4)
Good size for networking, discussion etc

Improvements:

Timing for call of abstracts and registrations and events
Better, more practical and longer workshops (6)
Vegetarian food options (2)
Conference proceedings ( should include all abstracts, in order with all Free Paper and Poster References)
More information on name tags
More free papers


THE DAVID RUSSELL AWARD 1999

This was awarded to Linda Kar, Carlos Scheinkestel, Ibolya Nyulasi and Michael Bailey for their paper entitled: "Comparison of Schofield Equation and Indirect Calorimetry in the Intensive Care Setting"

The Puritan-Bennett 7250 Metabolic Monitor uses indirect calorimetry to determine energy expenditure. Energy requirements are predicted using the Schofield equation, incorporating an estimate of the patient's weight and the clinician's judgement of an appropriate stress factor. This estimate has the potential to under or over estimate energy requirements. A retrospective audit was conducted to compare energy requirements predicted by the Schofield Equation with the energy expenditure measured by indirect calorimetry.

Forty intensive care patients (27 male, 13 female), mean age 51 years (range 18 - 81) were included. The Puritan-Bennett 7250 Metabolic Monitor was used at the bedside to measure energy expenditure continuously. Body weight was estimated for each patient. The basal metabolic rate was estimated using the Schofield Equation, multiplied by a stress factor to estimate energy requirements (mean stress factor = 1.5, range 1.2 - 2.0)

The ratio of estimated / measured energy expenditure was 0.93, indicating that the predictive equation underestimated energy expenditure on average by 7%. The use of the predictive equation and stress factor was significantly less accurate compared to measured values for patients with lower energy expenditure (p=0.03). This group of patients included respiratory failure and surgical patients for whom lower stress factors were used, and suggests that these less closely estimate actual energy needs than for the patient's given higher stress factors, including, multitrauma and burns.


THE BOB MACMAHON AWARD 1999

This was awarded to PA Ball, K Bethune, RLedger and MI Barnett for their paper entitled: "Particulate Contamination in Paediatric Parenteral Nutrition Solutions, Still a Cause for Concern".

Introduction

Previous studies have examined particulate contamination (PC) in various parts of the parenteral nutrition (PN) system. This study measured PC in fluids which had been passed through all the associated tubing and equipment, as would have been received by the patient.

Methods

Two in One mixtures and separate lipid emulsion in syringes supplied to paediatric patients (N=20) were sampled at the bedside immediately prior to connection to the patient. Samples from the line were drawn into prepared containers, sealed and returned to the laboratory for investigation. The samples were filtered through a 0.8 um pore size gridded membrane (Millipore AAWG 047 00). The particles were viewed by light microscopy and sized using an eyepiece graticule (G10, BS3260). Counts were cross validated between operators. Background counts derived from control runs were subtracted. Results

Paediatric PN 2 in 1
N = 20

Size in 
microns             >40     >25     >10     >5      <5

                               Particles / mL
                               
First 50mL  MEAN    0.16    0.38    1.43    11.77   7.59
            SD      0.23    0.26    1.09    7.38    2.56
            
Second 50mL MEAN    0.16    0.34    0.80    9.23    5.72
            SD      0.17    0.21    0.40    3.74    2.67
            
Lipid Emul  MEAN    0.57    0.92    1.85    9.98    18.5
5 mL        SD      0.42    0.38    1.37    4.24    11.2

CONCLUSION

PC is an unwanted contaminant that is still present in significant amounts in paediatric PN solutions. If in-line filtration were not employed, these particles would have been infused into patients.









THERMOGENESIS

Dr Tom Hartley, Pathology Dept., Royal Hobart Hospital

Introduction

One of the ongoing debates in nutritional support is "over" versus "under" prescription of nutritional formulae. This has provided the stimulus for this article - what is the physiological response to the provision of more nutrients than are required for metabolic balance and/or normal growth ?

Metabolic Rate

The common practice is to match nutritional prescription of 'energy' to an estimate of the metabolic requirement of the individual. This implies that we have a good idea of what the metabolic rate of an individual is. But what is the metabolic rate ? Metabolic rate is the Kilojoules of energy put into

Mechanical work in an organism is technically 'too difficult' to measure as are most of the other the other energy 'sinks' in the energy balance. So between the 1880's and 1940's, when there was a lot of experimental work being in this area, they drew upon the Law of Conservation of Energy. To apply this a fairly sweeping assumption was made viz. the eventual fate of all tissues is that they are totally returned back to the environment as simple component molecules - carbon dioxide and water - with all the energy that went into their synthesis being liberated as heat energy. In effect this was equivalent to them being 'burnt'. Then the overall energy balance in humans could be equated to the aerobic combustion of the daily diet / nutritional support prescription.

Carbohydrate combustion eg Glucose = C6H1206

Glucose + 6 O2 ---> 6 CO2 + 6 H20

Fat combustion eg Tristearin = C57H110O6

2 Tristearin + 163 O2 ---> 114 CO2 + 110 H20

The situation for proteins was and is not so straight forward. These molecules all contain nitrogen and some contain sulphur, hence the end products of combustion include nitrogen dioxide and sulphur dioxide.

Protein combustion eg alpha Casein fragment = C43H64O10N12

Casein + 63 O2 ---> 43 CO2 + 10 NO2 + 32 H2O

Nevertheless this 'combustion model' was found to be applicable to human metabolism when measurements were made, over periods of 24 hours or more, of heat production by individuals living and working in a whole body calorimeter. The data for carbohydrates and fats were in excellent agreement, see Table 1, with the 'combustion model' but there was a discrepancy for protein. The reason for this is that human metabolism only takes nitrogen and sulphur down to urea and sulphate.

TABLE 1 : Energy Production in Kilojoules per Gram of Carbohydrate, Fat and Protein

- Bomb Calorimeter Whole Body Calorimeter Generally Accepted Conversion factors
CHO 17.2 17.2 17
Fat 38.9 38.9 38
Prot 22.6 17.2 17

Practical Ways of Measuring the Metabolic Rate

Obviously the Whole Body Calorimeter was and still is an impractical way to measure metabolic rate in clinical situations. Fortunately in 1919 the empirical method of Harris and Benedict was published (A Biometric Study of Basal Metabolism in Man. Washington, Carnegie Institute, V 279, pp 40 - 44, 1919). This is an empirical expression for Heat Production in Man in Kilojoules :

For Men : 4.2 * [ 66.47 + 13.75 * Wt, kg + 5.003 * Ht, cms - 6.775 * Age ]
         
         = 279.2 + 57.75 * Wt + 21.01 * Ht - 28.46 * Age 
         
For Women : 4.2 * [ 655.1 + 9.563 * Wt, kg + 1.850 * Ht, cms - 4.676 Age, yrs ]

         = 2751 + 40.16 * Wt + 7.77 * Ht - 19.64 * Age

Other workers wanted to exploit the fact that oxygen consumption and carbon dioxide production must also be related to metabolic rate. At this point the concept of Respiratory Quotient, RQ, was introduced because from the 'combustion model' chemical equations you can see that the different substrates produce different amounts of carbon dioxide. It was proposed that the predominating type of substrate being metabolised at any one time could be identified at any time just by measuring the ratio of carbon dioxide produced to the amount of oxygen consumed by an individual :

Theoretical All Carbohydrate metabolism : 
                              RQ = (6 * 22.4L CO2) / (6 * 22.4L O2)
                                 =  1.00
                                 
Theoretical All Fat metabolism : 
                              RQ = (114 * 22.4L CO2) / (163 * 22.4L O2)
                                 = 0.70
                       
Theoretical All Protein metabolism : 
                              RQ = (43 * 22.4L CO2) / (63 * 22.4L O2)
                                 = 0.68

These theoretical RQ's were compared with measured and all agreed apart from that for protein. For reasons already mentioned the end products of protein metabolism in humans do not include nitrogen dioxide or sulphur dioxide. These molecules contain some of the oxygen used in the combustion, hence less oxygen ends up in carbon dioxide, so the theoretical RQ gets lowered. In aerobic metabolism more oxygen molecules end up in carbon dioxide molecules hence raising the RQ observed for protein. The experimental results were as shown in Table 2




TABLE 2 :
Component Carbohydrate Fat Protein
Energy Released, J 16.7 37.6 16.7
Oxygen consumed, L 0.81 1.96 0.94
Carbon Dioxide produced, L 0.81 1.39 0.75
RQ 1.00 0.71 0.80

In the experimental or clinical measurements of metabolic rate it is inaccurate to use measures of carbon dioxide production because there are large reservoirs of carbon dioxide, as carbonate and bicarbonate in the body, which buffer the concentration of carbon dioxide in expired breaths. Oxygen consumption, however, is not buffered in the tissues and can be readily determined using a face mask or hood and then measuring the steady state level of oxygen content in expired air.

The RQ observed for an individual on a 'mixed diet' is generally agreed to be about 0.85. An individual on a high carbohydrate diet can have a RQ of 1.00 or more and an individual relying heavily on metabolising fat reserves will have a RQ of 0.7 or reportedly less.

Thermic Response to Feeding

"Within 15 - 30 minutes after food enters the stomach the rate of thermogenesis rises to a peak at 30 - 60 minutes, and then gradually declines over the next 2 - 10 hours. This thermic response to food is associated with rises in the rate of oxygen consumption, carbon dioxide production, respiration rate, heat output, heart rate, heart stroke volume, cardiac output, myocardial oxygen consumption and systolic blood pressure. There is a fall in peripheral vascular resistance but no change in diastolic blood pressure." (Heymsfield et al in Chapter 26 of Nutrition and Metabolism in Patient Care, edited by Kinney et al, pub. by WB Saunders 1988.)

This chapter by Heymsfield et al. has some very interesting data on the response to feeding. Continuous enteral or parenteral feeding obliterates the peak and valley physiological response and replaces it with a steady raised physiological state - this is called a thermic response to fuel. The degree of elevation is determined by the rate of nutrient infusion, the composition of the nutrient formula infused and the patient's disease state.

Nutrient infusion rate - In nine normal individuals studied in the fasting state and then enterally with a maintenance formula the only statistically significant change was an increase in the heart rate by on average 5 beats per minute. Other investigations in eight normal individuals showed that doubling an enteral infusion of 40% fat, 15% protein and 45% carbohydrate produced easily discernable stepwise increases in metabolic rate, oxygen consumption, carbon dioxide production and respiration rate. Other studies showed that these responses were approximately linearly related to the nutrient infusion rate.

Formula Composition - Heymsfield et al also produced dose response data where they used high carbohydrate ( 15% protein, 2% fat, 83% carbohydate ) and high fat ( 15% protein, 50% fat, 35 % carbohydrate) enteral formulae. In fact they were able to produce sets of equations that confidently related the increases in physiological response to the dosage of formulae. The model equations were all of the form

Physiological Response = Slope * Dose + Intercept

It was quite clear that high carbohydrate feeds elicited approximately double the physiological response for all parameters apart from the heart rates :





- Slope : HIGH FAT FEED Slope : HIGH CHO FEED Units
Oxygen Consumption 36.5 62.0 mL/kg FFM/min
CO2 Production 29.0 71.4 mL/kg FFM/min
Ventilation Rate 0.94 1.91 L/kg FFM/min
Free Energy Production 0.17 0.32 kcal/kg FFM/min
(Dose was measured as kcal/kg FFM/min)

The protein content of feeds did not appear to affect any of these physiological parameters when used at maintainance dosage levels.

Parenteral infusions into patients also showed dose response effects with metabolic rate and heart rate both increasing with increasing doses of solution.

Disease State - The spectrum of effects on metabolic rate can be related primarily to the spectrum possible changes in body composition in disease and trauma states. Loss of lean tissue mass, loss of total body fat, insulin resistance, catecholamine excess, wound size, presence of infection all co-interact to give a variety of metabolic profiles that will respond diffrently to nutritional support.

Diet Induced Thermogenesis - Some Recent Papers

Westerterp Plantenga et al (1999) have studied diet and diet induced thermogenesis in eight normal women using a metabolic chamber. They controlled the activity levels, meal sizes and meal intervals so that they were identical throughout the studies. The high protein plus high carbohydrate diet was associated with significantly greater diet induced thermogenesis and satiety than the high fat diet.

Protein Carbo Fat D.I.T. Satiety
29% 61% 10% 14.6 +/- 2.9% More satient
9% 30% 61% 10.5 +/- 3.8% Less satient

Kopp Hoolihan et al (1999) have studied 10 women in pre-pregnancy and during pregnancy. They could find no predictive value between the pre-pregnancy measures of resting metabolic rate, diet induced thermogenesis, activity energy expenditure, energy intake and body fat mass and their handling of the additional energy intake associated with being pregnant. Each individual responded quite differently. However, they did observe a positive correlation between their resting metabolic rate and body fat mass, and a negative correlation between the cumulative change in their resting metabolic rate and the amount of fat deposited.

Mingrone et al (1999) have caried out test meal experiments in 18 stable Crohn's disease patients and matched them to the results from 12 healthy controls. As expected the fat mass was 27% less in the patients than in the controls. When they were given a test meal of 50.2 kJ/ kg body weight the patients had lipid oxidation rates that were 51% higher than the controls and diet induced thermogenesis was 74% more in the patients than in the controls.

- Crohn's Disease Controls Units Significance
Fat Mass 13.8 +/- 5.63 19.0 +/- 3.49 kg P<0.001
Lipid Oxidation 2.26 +/- 1.13 1.50 +/- 0.75 kJ/min P<0.05
D.I.T. 9.89 +/- 1.93 5.67 +/- 0.91 % of energy intake P<0.001

These results confirm that Crohn's disease patients have increased demands for fat and that a diet with as much fat as they can tolerate would be of benefit in improving their body composition.

Moukaddem et al (1997) investigated diet induced thermogensis in anorexia patients during refeeding. They found that when they gave them two energetic loads there was an exactly similar increase in the diet induced thermogenesis. Under both loads diet induced thermogenesis accounted for a 16% of the provided energy load which could go some way to explaining why these patients have an adaptive resistance to overfeeding.

Three papers by Sellden and Lindahl provide some interesting data on the thermic effects of intravenous amino acids observed during surgery. In their 1999 paper they demonstrated that by infusing an amino acid mixture at 125 ml/hr intraoperatively in a group of 45 patients then their length of hospital stay was decreased by a median of 2.7 days; (95% confidence interval 1.3 - 4.0 days). They observed that the principal determinants of length of stay were the duration of the surgery, the use of the intra operative amino acid infusion and the core temperature of the patient at the end of surgery. They found that the amino acid treated group had significantly higher body core temperatures, 36.5 ° C +/- 0.1, than the patients that received acetated Ringer's solution intravenously, 35.7 ° C +/- 0.1; (p<0.01). Their other two papers established that there was no eveidence of different stress levels in the treated and untreated groups and that nitrogen excretion for four days postoperatively were similar to pre-operative levels in the treated group, but the in the untreated patients nitrogen excretion fell.

References :











INTERNET NEWS

The Nutrition Screening initiative can be found at

www.fiu.edu/~nutreldr/NSI_main.htm

It is well worth looking at if your work involves the dietary therapy of elderly people. In addition there are some convincing USA financial statistics as to what savings flow on from proactive nutrition screening at the GP and Hospital's Preadmission Clinic level. They use the word DETERMINE as an acronym for a nutrition checklist :

D = Disease that affect nutrition
E = Eating too much or too little
T = Tooth loss and/or mouth pain
E = Economic hardship
R = Reduced social contact
M = Multiple prescribed medicines
I = Involuntary weight loss or gain
N = Needs assistance in self care
E = Elder years above age 80
There is also a pointer to a simple on-line self assesment calculator linked to the site at :

www.aafp.org/nsi/e-determ.html


CALENDAR 2000

January 23rd -26th 2000 : 24th A.S.P.E.N. Clinical Congress , Opryland Hotel, Nashville, TN, USA.
email: aspen@nutr.org

March 8th - 10th, 2000 : Intensive Care: Life on the Edge NZ National ANZICS Year 2000 Conference Contact: Dr Ross Freebairn. Phone 06 8788109 Fax 09 8781365
email rfreebairn@healthcarehb.co.nz

April 2nd - 8th, 2000 : International Course on the Epidemiology of Diet, Nutrition and Cancer, Sestri Levante, Italy Contact: International Agency for Research on Cancer, 150, Cours Albert-Thomas, 69372 Lyon Cedex 08, France Phone: +33 72 73 84 85 Fax: +33 72 75 85 75

July 23rd - 27th, 2000 : XIIIth International Congress of Dietetics, Edinburgh International Conference Centre, Scotland, United Kingdom. Contact Vicki Grant and Wendy Adesegun, c/o Meeting Makers, 50 George Street, Glasgow, G1 1QE, Scotland, United Kingdom. 44141 553 1930. Fax 44141 552 0511.
email: mm@meetingmakers.co.uk.

August 6th - 10th, 2000 : World Congress of Pediatric Gastroenterology and Nutrition, Boston, USA Contact: Professeur Maherzi Ahmed, 20 bis Avenue Taieb Mehiri-La Marsa, Tunisie
Email: ahmed.mehrzi@rns.tn

August 24th - 1st September, 2000 : 17th International Congress of Nutrition, Vienna, Austria Contact: Dr R. Janssen, Int. Union of Nutritional Sciences, c/o The Graduate School, VLAG, Dept. of Human Nutrition, Wageningen Agricultural University, PO Box 8129, 6700 EV Wageningen, The Netherlands

September 10th - 13th, 2000 : 22nd ESPEN Congress : Third Millenium - Improved Nutrition for a Better Life . Madrid, Spain. Contact ESPEN 2000, c/o MCI Congress, Rue de Lyon 75, CH - 1211 Geneva, Switzerland. Ph. +41-22-33-99-580 Fax +41-22-33-99-621.
email : espen@mci-group.com
Website : www.espen.org

September 17th - 20th, 2000 : Fourth International Conference on Dietary Assessment Methods, Sheraton El Conquistador Resort, Tucson, AZ. Contact Douglas Taren, Dietary Methods Conference, University of Arizona Prevention Center, PO Box 245163, Tucson, AZ 85719.
Internet: http://ahsc.arizona.edu/apc/conferences/dietmethods.htm.

October 16th - 19th 2000 : The American Dietetic Association Annual Meeting and Exhibition, Colorado Convention Center-Denver, CO. Contact: The American Dietetic Association, 216 West Jackson Boulevard, Chicago, IL 60606-6995. Tel: 312-899-0040;
email: mtgsinfo@eatright.org
Website: http://www.eatright.org.
Exhibit information contact: Lisa Nicola, 800-877-1600, ext. 4755. Attendee information contact: Frances Jennings, 800-877- 1600, ext. 4866.

October 26th - 28th 2000 : ANNUAL SCIENTIFIC MEETING OF AuSPEN TOBE HELD IN LORNE, VICTORIA. CONTACT Dr Julie Bines, Dept. of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, MELBOURNE, Victoria 3000, Australia.
Ph +61-3-9345-5060. Fax +61-3-9345-6240
email bines@cryptic.rch.unimelb.edu.au

November 12th - 16th, 2000 : XII Latin American Congress of Nutrition, Buenos Aires. Contact Sociedad Latinoamericana de Nutrici, 12vo Congreso Lantinoamericano de Nutrición, Bernardo de Irigoyen 240 (1072), Buenos Aires, Argentina. (54 322) 334 15445.
email: cesni@datamarkets.com.ar.
Website : http://www.nutrimail.com/slan/SLAI.htm

2001

21st - 24th January 2001 : 25th ASPEN Clinical Congress, Chicago, USA. Contact: ASPEN, 8630 Genton Street, Suite 412, Silver Spring, MD 20910 Phone: (301) 587-6315 or (800) 727-4567 Fax: (301) 587-2365 or (800) 905-7781
Email: aspen@access.digex.net












DISCLAIMER

The views and opinions expressed in this Newsletter are not necessarily the views and opinions of the Australian Society of Parenteral and Enteral Nutrition. Reports and articles on techniques, procedures and products are provided for the information of the Members of the Society and their inclusion does not imply any endorsements from the Australian Society of Parenteral and Enteral Nutrition. No liability can or will be accepted by AuSPEN or its agents for the third party use of information in this Newsletter.

Dr Tom Hartley, Editor, 27/02/2000.





Newsletter of the Australian Society for Parenteral and Enteral Nutrition
Editor : Dr Tom Hartley, 36, Pregnells Road, Sandfly, Tasmania 7150, Australia

Ph 03-6239-6475 (AH) 03-6222-8780 (BH) Fax 03-6231-3145
email hartley@southcom.com.au

AuSPEN WWW Homepage : www.southcom.com.au/~hartley/home.htm