ESSENTIAL NUTRIENT REQUIREMENTS

ESSENTIAL NUTRIENT REQUIREMENTS
Energy
For weight to remain stable, energy intake must match energy output. The major components of energy output are resting energy expenditure (REE)
and physical activity; minor sources include the energy cost of metabolizing food (thermic effect of food or specific dynamic action) and shivering
thermogenesis (e.g., cold-induced thermogenesis). The average energy intake is about 2600 kcal/d for American men and about 1900 kcal/d for
American women, though these estimates vary with body size and activity level. Formulas for estimating REE
are useful for assessing the energy
needs of an individual whose weight is stable. Thus, for males, REE = 900 + 10m, and for females, REE = 700 + 7m, where m is mass in kilograms.
The calculated REE is then adjusted for physical activity level by multiplying by 1.2 for sedentary, 1.4 for moderately active, or 1.8 for very active
individuals. The final figure provides an estimate of total caloric needs in a state of energy balance. For further discussion of energy balance in health
and disease,
Protein
Dietary protein consists of both essential and nonessential amino acids that are required for protein synthesis. The nine essential amino acids are
histidine, isoleucine, leucine, lysine, methionine/ cystine, phenylalanine/tyrosine, threonine, tryptophan, and valine. Certain amino acids, such as
alanine, can also be used for energy and gluconeogenesis. When energy intake is inadequate, protein intake must be increased, because ingested
amino acids are diverted into pathways of glucose synthesis and oxidation. In extreme energy deprivation, protein-calorie malnutrition may ensue
(Chap. 75).
For adults, the recommended dietary allowance (RDA) for protein is about 0.6 g/kg desirable body mass per day, assuming that energy needs are met
and that the protein is of relatively high biologic value. Current recommendations for a healthy diet call for at least 10 to 14% of calories from protein.
Most American diets provide at least those amounts. Biologic value tends to be highest for animal proteins, followed by proteins from legumes (beans),
cereals (rice, wheat, corn), and roots. Combinations of plant proteins that complement one another in biologic value, or combinations of animal and
plant proteins, can increase biologic value and lower total protein requirements.
Protein needs increase during growth, pregnancy, lactation, and rehabilitation after injury or malnutrition. Tolerance to dietary protein is decreased in
renal insufficiency (causing uremia) and in liver failure. Normal protein intake can precipitate encephalopathy in patients with cirrhosis of the liver.
Fat and Carbohydrate
Fats are a concentrated source of energy and constitute, on average, 34% of calories in U.S. diets. However, for optimal health, fat intake should total
no more than 30% of calories. Saturated fat and trans-fat should be limited to <10 and="and" calories="calories" fats="fats" of="of" p="p" polyunsaturated="polyunsaturated" to="to" with="with">monounsaturated fats comprising the remainder of fat intake. At least 45–55% of total calories should be derived from carbohydrates. The brain
requires about 100 g/d of glucose for fuel; other tissues use about 50 g/d. Some tissues (e.g., brain and red blood cells) rely on glucose supplied
either exogenously or from muscle proteolysis. Over time, adaptations in carbohydrate needs are possible during hypocaloric states.
Water
For adults, 1 to 1.5 mL water per kcal of energy expenditure is sufficient under usual conditions to allow for normal variations in physical activity,
sweating, and solute load of the diet. Water losses include 50 to 100 mL/d in the feces; 500 to 1000 mL/d by evaporation or exhalation; and,
depending on the renal solute load, 1000 mL/d in the urine. If external losses increase, intakes must increase accordingly to avoid underhydration.
Fever increases water losses by approximately 200 mL/d per °C; diarrheal losses vary, but may be as great as 5 L/d in severe diarrhea. Heavy
sweating and vomiting also increase water losses. When renal function is normal and solute intakes are adequate, the kidneys can adjust to increased
water intake by excreting up to 18 L/d of excess water (Chap. 340). However, obligatory urine outputs can compromise hydration status when there is
inadequate intake or when losses increase in disease or kidney damage.
Infants have high requirements for water because of their large ratio of surface area to volume, the limited capacity of the immature kidney to handle
high renal solute loads, and their inability to communicate their thirst. Increased water needs during pregnancy are about 30 mL/d. During lactation,
milk production increases water requirements so that approximately 1000 mL/d of additional water is needed, or 1 mL for each mL of milk produced.
Special attention must be paid to the water needs of the elderly, who have reduced total body water and blunted thirst sensation, and are more likely
to be taking medications such as diuretics.