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"ABSTRAKTujuan: Mengetahui status metabolisme penderita SHD rawat inap di rumah sakit, dan memperoleh rumus untuk menentukan kebutuhan energi yang sesuai dengan status metabolisme penderita.Tempat: Bagian Gizi dan Bagian Penyakit Dalam Rumah Sakit Sumber Waras, Jakarta.Metode Penelitian didisain Cross Sectional, pada 49 subyek SHD laki-laki atau perempuan 30-80 tahun yang diseleksi secara konsekutif, dan 40 kontrol sehat yang diseleksi secara random dari karyawan RSSW. Data REE diperoleh dari hasil pemeriksaan konsumsi O2 dan CO2 yang dikeluarkan tubuh, dengan mempergunakan Kalorimeler Indirek. Asupan makanan dicatat selama 3 hari berturut-turut sebelum pemeriksaan REE. Data antropometri (LLA, TLLBK, KAOLA, TB, dan BB) dan pengumpulan urin dilakukan satu hari sebelum pemeriksaan REE, pengambilan darah untuk pemeriksaan IGF-l dan GH dilakukan setelah pemeriksaan Kalorimetri Indirek. Uji Statistik: Univariat mempergunakan tes Kormogorov Smimov, Bivarial mempergunakan uji t tidak berpasang, uji Mann Whitney dan Korelasi Pearson. Uji multivariat mempergunakan uji regresi linier ganda.Hasil dari 49 subyek SHD yang masuk RS karena komplikasi: hematemesis (34,69%), malaria (46,94%), ikterus (55,1%), dan yang terbanyak asites (87,76%). Dari jumlah tersebut 67,35% tergolong Child C, sisanya Child B. Ditemukan 63,27 % subyek SHD mengeluh mual dan 75,52% anoreksia. Rerata asupan energi subyek SHD secara bermakna lebih rendah dari kontrol sehat (1282,04 ± 229,85 vs 1448,71 ± 325,56; p = 0,006), dan mempunyai korelasi dengan derajat penyakit. Proporsi asupan terhadap kebutuhan energi subyek SHD hanya mencapai 79,49% ± 17,60% REE. Proporsi asupan terhadap kebutuhan energi lebih besar pada subyek SHD yang tanpa keluhan mual dan anoreksia. Penelitian ini menemuken 73,57 % dari subyek SHD daiam keadaan malnutrisi, dan 58,26 % diantaranya (42,86% total subyek SHD) dalam keadaan muscle wasting (AOLA pada persentil < 5) dan menunjukkan korelasi dengan asupan energi (p=0,007). Meningkatnya mobilisasi lemak dan oksidasi substrat lemak ditandai oleh TLLBK pada lebih dari 67% subyek SHD pada persentil < 15 dan RQ = 0,7 ± 0,08, serta menunjukkan korelasi yang bermakna dengan kurangnya asupan energi (p = 0,005). Meningkatnya mobilisasi lemak dan lipolisis diduga mempunyai hubungan dengan rendah IGF-1 dan tingginya GH dalam darah. Walaupun oksidasi lemak diduga untuk mencegah berlanjutnya katabolisme otot, penelitian ini menunjukkan katabolisme otot berlanjut, hal ini ditandai dengan; imbang nitrogen negatif, rasio NUU/K.AOLA subyek SHD bermakna lebih tinggi dari kontrol sehat, dan RQ sekitar 0,43-0,86. Namun, pada penelitian ini tidak didapatkan perbedaan yang bermakna REE subyek SHD dengan kontrol sehat; hal ini disebabkan oleh menurunnya massa otot, dan meningkatnya oksidasi substrat lemak sehingga konsumsi oksigen dan REE rendah. Data menunjukkan rasio REE/K.AOLA bermakna lebih tinggi dari kontrol sehat. Keadaan ini menujukkan subyek SHD dalam kondisi hipermetabolisme disertai penyimpangan metabolisme yang dapat ditandai oleh berlanjutnya mobilisasi lemak; oksidasi substrat lemak (tak sempurna); dan oksidasi substrat protein berlangsung bersama. Asupan nutrisi, komposisi tubuh, dan status metabolisme penderita SHD telab diidentifikasi merupakan acuan penting untuk menentukan REE. Dengan menggunakan variabel; rerata asupan energi, komposisi tubuh (TB, BB, AOLA, dan lainnya) dan derajat penyakit (skor Child-Pugh, albumin, dan NUU) sebagai variabel independen. Melalui uji regresi linier ganda (metode STEPWISE) penelitian ini menemukan 3 variabel merupakan determinan kuat REE yaitu TB, AOLA dan kadar albumin. Dan uji tersebut diperoleh persamaan model yang merupakan model REE estimasi SHD yang reliabel, sehingga dapat direkomendasikan sebagai rumus estimasi REE atau kebutuhan energi penderita SHD yaitu :kebutuhan energi = -270,40+17,26*AOLA - 217,83*Albumin + 11,42*TB. Kesimpulan Pada penderita SHD, keadaan hipermetabolisme tidak dapat ditentukan hanya dengan indikator REE. Hipermetabolisme pada subyek SHD menjadi nyata dengan menentukan REE/K.AOLA dan NUU/K.AOLA. Nasib oksidasi makronutrien pada SHD berbeda dengan pada starvasi. Pada subyek SHD lerjadi rangsangan mobilisasi lemak, oksidasi substrat lemak, katabolisme protein otol, dan oksidasi substrat protein secara bersama. Keadaan yang membuktikan adanya penyimpangan metabolisme. Dengan uji regresi limier ganda (metoda STEPWISE), AOLA, albumin dan tinggi badan ditemukan sebagai determinan kuat dari REE atau kebutuhan energi pada penderita SHD rawat inap di RS.

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ABSTRACT

Objective: To study the metabolic status of the Decompensated Liver Cirrhotic (DLC) patients who were hospitalized, and to formulate the equation of energy requirements equal to their metabolic status.

Places: The Department of Nutrition and the Department of Internal Medicine at Sumber Waras Hospital (SWH), Jakarta.

The cross sectional study was carried out on 49 DLC subjects, aged 30-80 years, selected consecutively, and on 40 healthy control subjects, selected at random, from SWH staff. The REE data was determined by assessing the Oz consumption (V02) and CO2 production (VCO2] using an Indirect Calorimeter. Food intake was recorded for 3 consecutive days before determining REE. The anthropometrics data (AC, TSF, C.AMA, Height and Weight) and urine samples were assessed one day prior to determining REE. The blood samples for determining IGF-1 and GH were taken after the Indirect Calorimetric assessment (REE data). The statistical tests: Univarian (using Kormogorof-Smimov), Bivarian (using unpaired T-tests, Mann-Whitney and Pearson Correlation), Multivariate (using multiple linear regression).

Results The 49 DLC subjects were hospitalized mainly due to complications of ascites (87.76%); many also suffered with hematemesis (34.69%), melena (46.94%), or icterus (55.1%). Of the 49 subjects, 67.35% were classified as Child C, the rest were Child B. The subjective findings were nausea (63.27%) and/or anorexia (75.52%). The mean energy intake of DLC subjects was significantly lower than the control (healthy volunteers) (1282.74 229.85 vs. 1448.71 * 325.56; p = 0.006), and had a correlation to the degree of disease, Their intake had only been 79.49 17.60% of REE. The proportion of food intake to energy requirements was larger in the DLC subject who had no symptoms of nausea and anorexia. This study has proved that 73.57% of DLC subjects had malnutrition, and 58.26 % of them (42.86 % of all DLC subjects) were in a muscle wasting condition (the percentile of AMA < 5). Il showed a correlation to a decrease in the energy intake (p = 0.007). The increase of fat mobilization and lipid substrate oxidation were shown by the DLC subjects' TSF of more than 67% with a percentile of less than 15 and the mean RQ = 0.7 ± 0.08. This also had a significant correlation to a decrease in the energy intake (p = 0.005). The increase of fat mobilization and lipolysis was assumed to have a correlation with the low level of blood IGF-1 and the high levels of blood GH. The increase of lipid substrate oxidation was assumed to prevent the subsequent of muscle catabolism, however this study showed that the process of muscle catabolism does not end, which was marked by a negative nitrogen balance, a significantly higher the UNUIC.AMA than the control and a RQ of 0.43 - 0.86. In this study, there was no significant difference between the REE of the DLC subjects and the control; this was due to the decrease of muscle mass and the increase of lipid substrate oxidation. This caused a low V02 consumption and a low REE. This study showed REEIC.AMA of the DLC subjects was significantly higher than the control. This condition indicated that the subjects were hyper metabolic with several abnormalities in metabolism such as: continued stimulation causing lipid mobilization from adipose tissue; incomplete oxidation of fatty acid and protein substrate oxidation running together. Energy intake, body composition, the metabolic status of DLC patients was an important reference for the identification of the REE. By using variables which influenced REE, i.e. the mean energy intake, body composition (height, weight, C.AMA, etc.) and the degree of disease severity (Child-Pugh score, albumin, and UNU), which were tested by the multiple linear regression of STEPWISE method, the equation model has been formulated and tested The final equation for estimating energy requirement is:

Energy requirements = -270.40 + 17.26*AOLA - 217.83*Albumin + 11.42?Height.

Conclusion RITE is not the only indicator of hyper metabolism in DLC patients. Hyper metabolism can be identified in DLC patients using REFIC.AMA and UNUIC.AMA. This study has proved abnormalities in metabolism of DLC patients as follows: continued stimulation causing lipid mobilization from adipose tissue; oxidation of fatty acid; muscle protein catabolism; and protein substrate oxidation running together. Through multiple linear regression analysis (the STEPWISE method), AMA, albumin level and height have been found as strong determiners of REE or determiners of energy requirements for DLC subjects."

"ABSTRAKIt is well known that iron and zinc deficiencies have negative consequences on growth and development; therefore combined iron and zinc supplementation has been proposed to be applied at community level. However, studies on zinc supplementation and infant's growth have shown inconsistent results. While physiological factors may partly explain the variation in findings, contribution of care specifically psychosocial care to the outcomes has been less discussed. This study aims to investigate whether effect of micronutrient (zinc, iron, vitamin A) supplementation in improving infants' growth and developmental outcomes is modified by levels of psychosocial care. The main hypothesis of the study is that zinc and iron supplementation improves growth and developmental outcomes of the infants and that the effect is improved with more favorable psychosocial care. The study involved 800 infants aged 3-6 months living in the rural area of East Lombok, West Nusa Tenggara. The main study was a double-blind community intervention study where syrup -consisting of zinc alone, Z (10 mg/d), zinc+iron, ZF (10 mg of each/day), zinc+ iron+ vitamin-A, ZFA (10 mg/d for each zinc and iron, 1,000 IU for vitamin-A), or placebo-- were given in daily dose for six months. The measured outcomes were growth, index on mental (MDI) and psychomotor (PDI) development using Bayley Scale of Infant Development II (BSID II), and micronutrient status (hemoglobin, serum zinc, ferritin, and retinol). Psychosocial care was assessed using Home Observation for Measurement of the Environment (HOME) Inventory scale. Other data included morbidity, food intake, childcare practices, resources for care, and socio-economic condition. Significant effect on serum zinc was observed in Z, ZF and ZFA groups and on serum retinol in ZFA group (p<0.05). Prevalence of anemia and low iron storage (ferritin <10 µg/L) remained the same in ZF and ZFA groups while increased (p<0.01 for hemoglobin, p<0.05 for ferritin) in Z and placebo groups. In general there was no significant effect of the supplementation on growth (HAZ, WHZ, WAZ). However, positive response on linear growth (HAZ) was observed among initially stunted infants, especially stunted boys who receive both zinc and iron (ZF and ZFA groups, p<0.05). There was an improvement of mental development in all groups, but only significantly in ZF group (p<0.05). In addition, subjects whose anemia remained uncorrected had significantly lower mental scores than those who were not/ no longer anemic (p<0.05). Better psychosocial care was associated with better growth, and the difference in growth among upper and lower levels of psychosocial care is minimal in the infants who received iron-zinc supplementation, suggesting that both supplementation and psychosocial care had an effect on growth. However, during the six-month supplementation, combination of both supplementation and better psychosocial care was not more significant than interaction of iron-zinc supplement and male sex (for HAZ) or levels of psychosocial care alone (for WAZ). Growth is determined not only by micronutrient intake and status but also by the contributing role of psychosocial care. Psychosocial care affected growth indirectly through better nutrient intake and health practices, and possibly through direct mechanism, which was not yet identified. The effect of zinc+ iron supplementation on mental development was stronger when combined with better psychosocial care and higher hemoglobin level. Accelerated mental performance was also observed in placebo, suggesting that factor(s) other than nutritional factor(s) may influence mental performance. On the other hand, psychomotor outcome was more predicted by nutritional status (WAZ), age, nutrient intake and illness. Results from this study concluded that mental development was determined both by micronutrient status and psychosocial care. Psychosocial care affected mental development partly through better initial mental performance, but mainly direct suggesting that environmental factor(s) had a stronger role than initial status in determining mental performance. Six months after the supplement was no longer given, growth (HAZ, WAZ, WHZ) remained better in infants having better psychosocial care. The association between growth (HAZ, WAZ) and HOME score at six months after the end of supplementation became stronger than during the intervention period, whereas positive benefit of the supplementation on -HAZ among boys -as observed by the end of the 6-month supplementation- was no longer maintained at this point of time. During the six-month supplementation, the subsequent six months, and over the total 12-month period, nutrient intake together with illness and psychosocial care were significant determinants of nutritional status (HAZ and WAZ). Results of this study suggest that incorporating care elements including encouragement of psychosocial care in supplementation/nutritional programs should improve its effectiveness and sustainability. The study also recommends further study to investigate more optimal iron: zinc ratio (probably more than 1:1) when given to anemic, iron deficient subjects and to investigate the mechanism connecting psychosocial care and nutrition/ health outcomes. "