kuliah blok 16

8/13/2019 Kuliah Blok 16

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Brain Growth

There are two peaks of brain growth, about 26 weeks of gestation and around birth. In the brain

stem, DNA synthesis ontinues at a s!ow but steady rate unti! at !east " year of age. In most regions of the

brain, the tota! number of e!!s present in adu!ts is !arge!y determined by the end of the first year of !ife

Infants who weighed 2000 gr or less at birth and who died of severe undernutrition during

the first year of life have a reduction of 60% total brain cell number

In #e$io and Guatema!a psyho!ogia! tests was found to be re!ated to dietary pratie and not to

differenes in persona! hygiene, housing, ash inome, rop inome, proportion of inome spent on food,

parenta! eduation, or other soia! or eonomi indiators. %erformane of both preshoo! and shoo!

hi!dren on the Terman and Goodenough draw&a&man tests was positi'e!y orre!ated with body weights and

heights Beause the shorter hi!dren did not ome from fami!ies signifiant!y !ower in soio&eonomi

fators, housing, and parenta! eduation than those of the ta!!er hi!dren, it was on!uded that the most

important 'ariab!e ref!eted by the short stature was poor nutrition during ear!y !ife and that this a!so !ed to

the !ag in de'e!opment of sensory integrati'e ompetene. In a study done in Jamaica, all of the children

from a low-income group undernourished at any time during the first 2 years of life had significant

behavioral abnormalities at school age

study was conducted to a population of !orean children" some were severely

undernourished during the first year of life and then adopted by families in the #$. ll of the infants

were adopted before their second birthday by merican families. They were then !assified as

ma!nourished, moderate!y ma!nourished, and we!! nourished. By the time they reah ( years of age, there

were no differenes in a'erage weight among the three groups and a!! reahed norma! )orean standards.

*hanges in height were simi!ar to those in weight e$ept that the undernourished hi!dren remained s!ight!y

but signifiant!y sma!!er.The mean I+ of the pre'ious!y undernourished groups was "2.-. The margina!!y nourished

hi!dren ahie'ed a mean I+ of "-.-. This is not a statistia!!y signifiant differene. The pre'ious!y

we!!&nourished hi!dren reahed a mean I+ of """.6/, whih does represent a signifiant differene from

the undernourished hi!dren.

The data a!so suggest that when we!!&nourished hi!dren are p!aed in a more stimu!ating

en'ironment they do e'en better. In a!! pre'ious studies, when the hi!d was returned to his or her pre'ious

en'ironment, the I+ was ( or be!ow at shoo! age.

In a study in *o!ombia, se'ere!y undernourished hi!dren after reo'ery ha'e been p!aed in an

enrihed en'ironment at about 2 years of age. The hi!dren are e$posed to a!! types of stimu!ating !earning

and p!ay e$perienes. Their nutrition has been kept ade0uate. %re!iminary resu!ts show that the test !e'e!sof the stimu!ated undernourished hi!dren are higher than those of the hi!dren from the higher soio&

eonomi group who were not stimu!ated. 1esu!ts show that the we!!&nourished and stimu!ated hi!dren

ha'e the highest !earning apaity.

ryptophan and $erotonin

Tryptophan is the preursor of erotonin. It is an essentia! amino aid and is found in a!! high&

0ua!ity proteins.

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erotonin is needed to regulate sleep, secrete pituitary hormones, and perceive pain. he

levels of serotonin in the brain can be altered by ingestion of tryptophan.

3n a high&protein mea! is eaten, on!y a sma!! amount is on'erted to serotonin. It is beause

tryptophan must ompete with other amino aids to enter the brain. 4hi!e after a arbohydrate&rih mea!,

insu!in auses these ompeting amino aids to !ea'e the b!ood and enter mus!e tissue.

#ore tryptophan enters resu!ting drowsiness. %eop!e who eat a high&arbohydrate !unh are !ess

a!ert fo!!owing the mea! than peop!e who eat a sma!!, high&protein !unh

&ecithin, 'holine, and cetylcholine

*ho!ine is deri'ed most!y from !eithin in eggs, !i'er, soybeans, and food additi'e of mayonnaise

and hoo!ate. The effet that ho!ine has on aetyho!ine N513T1AN#ITT51 is !ess dramati than

that in the tryptophan&serotonin onnetion. Anima!s in7eted with ho!ine ha'e inreases in aety!ho!ine

!e'e!s in the brain, though not as high as the tryptophan&serotonin reahtion. It is due to the fat that

transport of ho!ine from the b!ood into the brain and the subse0uent synthesis of aety!ho!ine are more

omp!e$ omparing to the tryptophan&serotonin system.

*ho!ine supp!ementation has produed some promising resu!ts in treating tardi'e dyskinesia.*ho!ine has a bitter taste and auses an ob7etionab!e fishiy body odor in peop!e who take it, making it an

unp!easant treatment. Gi'ing !eithin instead of ho!ine resu!ts a simi!ar suess in treating tardi'e

dyskinesia without the same drawbaks. %ure !eithin is, howe'er, a bu!ky, wa$y substane that must be

taken in !arge amounts to be effeti'e and added a nine a!ories a gram to a person8s diet.

%eop!e with A!9heimer8s disease :who tend to be defiient in aety!ho!ine; gi'en

supp!ementation ha'e no dramati resu!ts and suggest that this approah is not effiaious in A!9heimer8s

disease or in enhaning memory

yrosine and the 'atecholamines

The *ateho!amines in!udes epinephrine, norepinephrine, and dopamine. 5ating a high&protein

mea! inreases the amount of tyrosine in the b!ood fo!!owed by the !e'e!s in the brain. A more effeti'e

means is ingestion of a pure tyrosine supp!ement with arbohydrates that stimu!ates insu!in seretion.

Inrease in brain tyrosine wi!! inrease the !e'e!s of ateho!amines, partiu!ar!y dopamines. This

strategy has a potentia! benefit for patients suffering from %arkinson8s disease. The effet of !e'odopa

e'ident!y has a simi!ar effet to that of tyrosine.

Tyrosine has a!so been used with !imited suess to treat depression, probab!y by inreasing the

!e'e!s of norepinephrine. But tyrosine has not been appro'ed by the


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=itamin B"2 defiienies auses anemia and neuro!ogi damage whih in turn damages menta! funtion.

in is another minera! that is essentia! in a number of ma7or biohemia! proesses that affet

brain funtion. *opper is a!so essentia! to norma! funtioning of the entra! ner'ous system. Diseases suh

as #enkes8 disease whih auses inade0uate intestina! absorption of opper !eads to brain and growth

retardation in infants. 3n the other hand, 4i!son8s disease is the resu!t of gradua! aumu!ation of opper in

the body tissues, in!uding the brain. The resu!t, o'er time, is a deterioration of menta! funtion.

The minera! #anganese is essentia! for norma! brain funtion. It appears to be in'o!'ed in the

on'ersion of !e'odopa to dopamine in the brain. But e$esses of manganese in the brain is found in

%arkinson8s disease and some forms of dementia, a!though no know!edge is a'ai!ab!e on its ro!e in the

de'e!opment of these onditions

?igh !ead and merury !e'e!s resu!t in entra! ner'ous system abnorma!ities that may !ead topersona!ity hanges, irritabi!ity, and s!eep disturbanes. *a!ium and magnesium a!so p!ay a ro!e in some

brain funtions. ?ypoa!aemia an produe menta! aberrations.

*rthomolecular and )egavitamin herapy

3rthomo!eu!ar therapy is defined as the @treatment of menta! disease by the pro'ision of the

optimum mo!eu!ar en'ironment for the mind, espeia!!y the optimum onentration of substanes

norma!!y present in the human body. The word @optimum !e'e! appears to be a synonym for megadoses

of 'itamins.. The therapy in!udes niain, 'itamin *, B6, B"2, fo!i aid, minera!s, hormones, diets that

redue b!ood&g!uose !e'e!s, and diets free of foods a!!eged to ause a!!ergies.

In "(, A%A found no e'idene to support the pratie of it, and harateri9ed the under!ying

therapy as superfiia!, inonsistent, and ontraditory. #ost !aims that !arge doses of 'itamins are usefu!

in treating brain&funtion disorders !ak support from ontro!!ed studies.

%re!iminary researh a!!eges that !arge doses of 'itamin B6 might be benefiia! in treating some

autisti hi!dren. In two studies of autisti hi!drean C both of whih ha'e been a!!ed into 0uestion in terms

of their 'a!idity C impro'ement was seen with administration of 'itamin B6.


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+yperactivity in 'hildren

The use of diet therapy to treat hyperati'e hi!dren has a!ways been 0uestionab!e. Dr. Ben7amin


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a-&inolenic cid &1

AEA is known as "/F n&, with a hain !ength "/ arbons !ong and three bonds that are

unsaturated. It is found in f!a$ and f!a$seed oi!, ano!a oi!, soybeans, and peri!!a, as we!! as in se'era!

'arieties of nuts and their oi!s. It an funtion as a preursor for the n& fatty aids eiosapentaenoi aid

:5%A; and doosahe$aenoi aid :D?A;, with a !ow on'ersion e'en in the most optimum nutritiona!

onditions, and !imited 'ariety of 'itamins and minera!s further !imits it. This has made most e$perts do not

reommend the re!iane of AEA as a soure of 5%A and D?A.

icosapentaenoic cid 1 and 3ocosahe4aenoic cid 3+1

5%A :2F- n&; is primari!y found in fish. nder onditions of tissue D?A saturation, D?A an

@retroon'ert into 5%A.

D?A :22F6 n&; is a!so primari!y found in fish, whih obtain it by eating marine a!gae. D?A is

stored in the fish8s mus!e tissue and an a!so be obtained from marine a!gae as supp!ements.

3#5GA&


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Dietary manipu!ation and restrition annot speify whih type of fat is !ost. 5'en an omega&

AEA supp!ementation during a weight !oss diet has been found not to preser'e n& stores in tissue. Two or

more generations of D?A defiieny :aused by restriti'e eating; affet brain funtion, speifia!!y spatia!

!earning and o!fatory&ued re'ersa! !earning task.

5oal ;7 Increased ntio4idant Intae

#aintenane of hea!thy fatty aid !e'e!s ha'e 2 goa!s F to inrease the !e'e!s through dietary

hoies and to pre'ent their o$idation through dietary food hoies. A!though D?A is an antio$idant,

another antio$idant may preser'ing these fats, so a good supp!ement shou!d ontain 'itamin 5.

A diet rih in fruits and 'egetab!es is an important strategy. In addition, when prepared with

'inaigrettes and marinades, they an be important arriers of omega& fatty aids.

C Anore$ia Ner'osa :AN;

C Bu!imia Ner'osa :BN;

C 5ating Disorders Not 3therwise peified :5DN3;C Binge 5ating Disorder :B5D;

The treatment of eating disorders re0uires a mu!tidisip!inary approah in!uding psyhiatri

psyho!ogia!, media!, and nutritiona! inter'ention. The nutritiona! rehabi!itation in!udes nutrition

assessment, media! nutrition therapy :#NT;, nutrition ounse!ing, and nutrition eduation. A!though the

eating disorders are distint i!!ness, simi!arities e$ist in nutritiona! onse0uenes and nutritiona!

management. Nutrition assessment routine!y in!udes a diet history and the assessment of biohemia!,

metabo!i, and anthropometri indies of nutrition status

DI5T?IT31

In diet history, the assessment of energy intake, maro L mironutrient onsumption, eatingattitudes L beha'iors shou!d be in!uded in the guide!ines. sua!!y an AN patient onsume !ess than "

ka! per day, and they usua!!y o'erestimate their food and energy intake. Assessing typia! energy intake

wi!! pre'ent o'erunderfeeding at the start of rehabi!itation and open a dia!ogue regarding a!ori

re0uirements during the refeeding and weight maintenane phases

BN patients energy intake may be unpreditab!e due to the a!ori ontent of a binge, the degree

of a!ori absorption after a purge, and the e$tent of a!orie restrition between binge episodes. Though

they assume that 'omiting may e!iminate a!ories onsumed during the binge episodes, a study of "( BN

sub7ets onsuming a mean of 2"" ka! during binge, the a!orie e!iminated during the 'omit was on!y

( ka!. This !eads to a on!usion that energy e!imination is be!ow energy onsumption. Another

assumption is that the a!orie onsumed during a binge an be omp!ete!y purged is a!so a misoneption.

As a ru!e of thumb, M- energy onsumed during a binge is retained after purging.

Inade0uate intake resu!ts in dereased onsumption of arbohydrate, protein and fat. AN patients

tend to a'oid arbohydrate and fat ontaining foods. And as a!orie intake drops, the amount of

arbohydrate, fat, or protein intake is a!so redued, a!though the re!ati'e to tota! a!ori onsumption may

not. It is beause the perentage ontributed is re!ati'e to tota! amount of a!ori intake, and this may be in

the a'erage to abo'e&a'erage range. This, with !imited 'ariety and poor food group representation, wi!!

resu!t in inade0uate 'itamin and minera! onsumption. In genera!, mironutrient intake para!!e!s

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maronutrient intake :fat fatty aid L fat so!ub!e 'itamins;. o it is important to ompare the a!ori

intake with D1I.

#any AN patients fo!!ow 'egetarian diets. This affets the 0ua!ity and 0uantity of protein intake.

Assessment of the patient8s diet history before AN and the fami!y diet may be re0uired. It is important to

know whether the patient fo!!owed 'egetarianism before or after she de'e!op AN.

Beause of day&to&day 'ariabi!ity in eating disorder, a 2&hour rea!! is not partiu!ar!y usefu!. It is

better to estimate dai!y food onsumption o'er the ourse of a week.


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1esting energy e$penditure :155; is harateristia!!y !ow in ma!nourished AN patients, basa!

metabo!i rate fa!!s as muh as "&"- to onser'e energy, and refeeding wi!! inrease it. ?owe'er, in

some ases the inrease in 155 is e$essi'e and presents as metabo!i resistane to weight gain.

BN patients an ha'e unpreditab!e metabo!i rates. Dietary restraint may p!ae them in a state of

semistar'ation :a hypometabo!i rate; and binge&purge an inrease the metabo!i rate seondary to a

preabsorpti'e re!ease of insu!in.

ANT?13%3#5T1I*A5#5NT

A goa! of nutritiona! rehabi!itation is restoration of body fat and fat&free mass. Body weight is

assessed and routine!y monitored in patients with eating disorders. In AN, weight gain is neessary whi!e in

BN, weight maintenane is the short&term goa!. In genera!i9ation, a hange of - ka! in a!ori intake is

fo!!owed by a hange of " !b in body weight. A!though the tota! body fat norma!i9es after short&term weight

restoration, the distribution may not be norma!.

T?5#5DI*AENT1ITI3NT?51A%AND*3N5EING

AN315OIAN51=3A

Treatment of AN may begin at one of four !e'e!s of are depending on the se'erity of

ma!nutrition, degree of media! and psyhiatri instabi!ity, duration of i!!ness, and growth fai!ure. ome

begin with inpatient hospita!i9ation and stepped down, others may begin on an outpatient basis and may

step up.

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There are no outome studies to suggest that one method is better than others, and despite the

differene, AN patients onsistent!y find it diffiu!t to make food hoies, and the 1egistered Dietitian

:1D; an be e$treme!y he!pfu!.

In an outpatient setting, the team has !ess ontro! o'er the hoies, so the 1D must use ounse!ing

ski!!s to begin the p!an de'e!opment. AN patients are typia!!y preontemp!ati'e or ambi'a!ent about

making hanges in eating beha'ior, diet, and body weightJ some are defiant and hosti!e on initia!

presentationthe nutrition ounse!or an he!p to reso!'e the ambi'a!ene.

reatment lan and 'aloric rescriptions

The treatment p!an shou!d in!ude an e$peted rate of weight gainF about 2& !bweek for

hospita!i9ed patient and .-&" !bweek for the outpatient. *a!ori presriptions in the range of "&"6

ka!day are suffiient to initiate weight gain, and must progressi'e!y inrease :about "&2 a!ories per

2& days; to promote ontro!!ed weight gain. Aggressi'e refeeding of se'ere!y ma!nourished AN patients

may preipitate !ife&threatening omp!iations of the refeeding syndrome during the first week of ora!,

nasogastri, or intra'enous refeeding. %ara!!e! to weight gain, the a!orie intake shou!d a!so be inreased,

with a measure of (&" ka!kg of body weight, as we!! as an inrease in ati'ity shou!d a!so be in!uded.In genera!, the presription is about & ka!day, and &- ka!day for ma!e.

After the goa! is ahie'ed, a!ori presription may be s!ow!y dereased to promote weight

maintenane. *a!ori presription in ado!esents may remain higher due to growth and de'e!opment.

5uidelines for )edical


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5oals of


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o'er!ap in the ounse!ing sessions. If the BN patient is engaged in a type of psyhotherapy other than *BT,

the 1D shou!d inorporate more *BT ski!!s into the nutrition ounse!ing sessions.

BING5&5ATINGDI31D51

o trategies for treatmentF nutrition ounse!ing and dietary management, indi'idua! and group

psyhotherapy, and mediation.

o Goa! of treatmentF e!f&aeptane, impro'ed body image, inreased physia! ati'ity, and better

o'era!! nutrition.

NT1ITI3N5D*ATI3N

Though patients tend to ha'e know!edge about food and nutrition, nutrition eduation is sti!! an

essentia! omponent of the treatment p!an. The patients may reei'e from unre!iab!e soures or ha'e

distorted interpretation. And remember to hoose the information arefu!!y. A soure that indiates a !ow&

fat !ow&a!orie intake for pre'enting hroni disease is not orrespondent to the treatment p!an.

%13GN3I

1e!apse rates after weight restoration in AN is high, as many as - patients re0uiring

rehospita!i9ation within " year of inpatient treatment. Two thirds of AN wi!! ha'e enduring food and weight

preoupation. Ado!esents ha'e better outomes than adu!t, and younger ado!esents is better than o!der

ado!esents.

#orta!ity rates in AN is among the highest in psyhiatri i!!ness. AN women are "2 times more

!ike!y to die than women of simi!ar ages in the genera! popu!ation. Appro$imate!y ha!f of these deaths are

due to the effets of e$treme emaiation and about ha!f to suiide :%a!mer, ";.

BN patients ha'e a short&term suess rate of -&(, and a re!apse rates of &/-.

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