Block 5

M a
METABOLISM AND
n u a l
f o r
T u t o r
ENERGY
Second Edition
200
9
Contributor:
dr. Ardiana Ekawanti, M.Kes
dr. Bobby Marwal Syahrizal, MPH
dr. Dyah Purnaning
dr. Eustachius Hagni Wardoyo
dr. Herpan Safii H.
dr. Muhammad Farid Wajdi, Sp.PD
Fakultas Kedokteran
Universitas Mataram
Metabolism and energ y

M a n u a l f o r Tu t o r
Second edition 2009
Editor:
Bobby Marwal Syahrizal
Block coordinator:
dr. Dyah Purnaning
Contributor:
dr. Ardiana Ekawanti, M.Kes
dr. Bobby Marwal Syahrizal, MPH
dr. Dyah Purnaning
dr. Eustachius Hagni Wardoyo
dr. Herpan Safii H.
dr. Muhammad Farid Wajdi, Sp.PD
Fakultas Kedokteran
Universitas Mataram
Preface
Healthy individual requires sufficient amount of nutrients
every day. Since human body cannot synthesize all of the
required nutrients, ones always need to consume adequate
and appropriate food. Availability of nutrients within the
human body is largely influenced by the function of
alimentary tract in which the digestion and absorption of
nutrients take place. Furthermore, after being absorbed,
these nutrients still not usable by cells and tissues. A range
of metabolism processes still occurs to transform them into
substrates that can be used directly by cells and tissues.
Students will learn these concepts in the nutrition and
metabolism block.
Within this block, various learning strategies will be applied
to provide students with a better understanding of nutrition
and metabolism concepts. A problem based approach is at
the heart of the learning strategies. This method requires
active participation of students within the whole learning
process in which, therefore, students are at the centre of the
learning process.
Since students participation is necessary, the role of tutors
are crucial in facilitating students to study independently and
actively participated in all learning activities. This manual is
developed to assist tutors during several learning activities
within this block. We realize that this guidebook has some
limitations or faults. Therefore, suggestions and comments
are largely appreciated.
Mataram, April 2009
Author
Tab l e o f C o n t e n t s
Introduction
______________________________________
Expected Outcomes
_______________________________
Tutorials________________________________________
_
Evaluation
_______________________________________
2
6
References______________________________________
_
2
8
Time Table ______________________________________
2
9
Metabolism
1 and Energy
Introduction
Block Name: Metabolism and Energy
The metabolism and energy block emphasizes on digestion,
metabolism and utilization of nutrients to fulfill human body
requirement. The digestion processes include mechanical
digestion, chemical transformation and nutrient absorption in
gastrointestinal tract. When nutrients enter the body, a sort of
chemical transformation processes converts these nutrients into
energy and other products required by the body. These products
are then used for growth and development, repair of damaging
tissues, basal metabolism and activities. Remaining nutrients are
put as deposit in certain part of the body.
Figure
Conceptual
1.
basis for understanding nutrition & metabolism
Requirement
Macronutrients
Micronutrients
Mechanical digestion
Chemical transformation
Nutrient absorption
Metabolism
Chemical transformation
Utilization
Basal metabolism
Growth & development
Tissue repair
Nutrient deposit
Activity
Sickness
Inside the human body
Digestion
Introduction
In individual with certain illness, nutrients requirement will be
difference. More energy may be required to fulfil high metabolism
processes while some other nutrients are required to repair
damaged tissues. This concept is summarized in figure 1.
While learning in this block, students need to understand the
concept illustrated above in depth. It is than link with several clinical
settings, i.e. nutritional, organ and metabolic disorders. To facilitate
this understanding, two major themes applied in this block,
including 1) nutrition for normal individual well-being, 2) nutrition in
certain clinical settings, i.e. nutritional, organ, and metabolic
disorders.
The first theme, nutrition for normal individual well-being, is
addressed to answer the following question:
Where can people get required nutrients from?
What will happen when food enters the gastrointestinal tract?
What are the roles of nutrients for normal individual?
Will the requirement differs in various stages of life?

Studies have shown that nutrition is essential in maintaining human
well-being, particularly nutrients that cannot be synthesized by the
body. The essential amino acids, water-soluble and fat-soluble
vitamins, minerals, and the essential fatty acids are among these
essential nutrients. The body also requires an adequate energy
substrate, a small amount of metabolizable carbohydrate,
indigestible carbohydrate (fiber), additional nitrogen, and water.
This requirement of nutrients varied in different stages of life, i.e.
newborn, infant, childhood, adolescence, adult, the elderly, and
pregnancy. In general, nutrients are required for producing energy
for work, basal metabolism, growth and tissues repair, and
regulation of the body function1. The balance between intake and
utilization of nutrients will then determine the well-being of
individuals.
1 Almatsier, S, 2002. Prinsip dasar ilmu gizi. Jakarta: PT Gramedia

Pustaka Utama.
Metabolism
3 and Energy
In order to fulfil adequate amount of nutrients, a person needs to
consume various source of food in a considerable amount.
Different dietary products provide a variety of essential nutrients.
Furthermore, when foods enter the body, they undergo a range of
digestive process in the human gastrointestinal tract, which include
physical and chemical processes. Some nutrients are absorbed
loosely while others are absorbed in very small amount. Therefore,
ones need to know the function of gastrointestinal tract in providing
nutrients for the body. After being absorbed, what will happen to
those nutrients? Will it be utilized directly?
A range of metabolism process is required to transform circulated
nutrients into substrates that can be used directly by human
tissues. The nutrients may be used for different purposes in the
body. Once there is an excessive amount of nutrients, they will be
stored as nutrient deposit or excreted. The equilibrium of intake and
utilization is necessary to ascertain the normal functioning of the
body.
Clinically, imbalance nutritional intake and requirement may result
in several disorders, e.g. deficiency syndrome (vitamin A
deficiencies, stunting, wasting, etc) and over nutrition (obese,
vitamin toxicity, etc). Disorders of organ and metabolism, e.g.
diabetes, renal failure, heart disease, liver abnormalities,
hypertension, and diabetes, may influence nutritional stability.
These disorders may lead to decrease or increase excretion,
detainment of nutrients in the blood vessels, etc. The second
theme will provide the foundation of understanding the clinical
consequences of under- and over nutrition, as well as the
nutritional adjustment in certain organ and metabolic disorders.
Duration of the block: 7 effective weeks
Eligibility for this block:
Have completed block 1, 2, 3 and 4
Didnt fail more than 2 previous blocks
Expected Outcome
Expected Outcome
After completed this block, students are expected to be able 1) to
construct dietary plan for normal individual, 2) to construct dietary
plan for patient with nutritional disorder (malnourished individual),
and 3) to construct dietary plan for patient with organ disorders
(kidney, heart and liver) and metabolic disorders (diabetes and
hypertension), 4) to practice long life learning, and 5) communicate
effectively with colleagues and other professionals. In order to
achieve this outcome, students should master the following
constructs:
1.1. Explaining the anatomy, physiology and histology of
digestive system in providing nutrients and maintaining
energy stability.
1.2. Explaining the principles of human diet (source and
metabolism of nutrient).
1.3. Explaining the nutritional requirement in different lifecycle.
1.4. Explaining the concept of energy stability, energy
production and expenditure.
1.5. Able to collect and apply basic interpretation skills in a
given data regarding diet (secondary data) to validate
scientific information systematically.
1.6. Able to use data and scientific evidence in approaching
individual dietary plan.
1.7. Performing anthropometric measurements to assess
nutritional status.
1.8. Identifying, deciding, and determining appropriate
laboratory measurement to assess nutritional status.
2.1. Explaining the pathogenesis and pathophysiology of
nutritional disorders (nutrient deficiencies and excessive
syndromes).
2.2. Explaining the effect of non biological factors related to
nutritional disorders.
2.3. Explaining the principles of drug and food interaction on
gastrointestinal tract.
2.4. Interpreting and explaining clinical and laboratorial data to
determine the diagnosis of nutritional disorders.
2.5. Explaining common health promotion and preventive

approach related to community nutrition.
3.1 Explaining the principles of dietary treatment for patient
with organ and metabolic disorders.
3.2 Exploring and recording clearly dietary plans for patients
with organ and metabolic disorders.
3.3 Explaining and deciding when to give parenteral and
enteral dietary route.
3.4 Providing sufficient time and paying attention to when
other professionals (dieticians) expressed their idea or
consideration.
4.1 Developing capability to follow up with scientific and
technological advancement.
4.2 Critically analyze medical literature and appropriately
applied to students patient.
5.1 Appreciating others without preferences in certain
personal status.
5.2 Presenting a case clearly and efficiently.
5.3 Constructively responding other people opinions
5.4 Providing sufficient time and paying attention to when
other professionals (dieticians) expressed their idea or
consideration.
The following objectives are required in developing understanding
related to the constructs above:
1.
2.
3.
4.
5.
Explaining the anatomy of gastrointestinal tract and its related

apparatus and glands
Explaining the histology of gastrointestinal tract
Explaining the basic principle of gastrointestinal tract function,
including a) the motility of, b) the neurological and hormonal
control of, and c) blood flow regulation of gastrointestinal tract
Explaining the secretory function of gastrointestinal tract,
including a) gastrointestinal secretion, b) types and
characteristics of gastrointestinal glands, c) factors determining
gastrointestinal secretion, and d) bile composition and function.
Explaining the transport and absorption mechanism nutrition in
gastrointestinal tract, including a) digestion process (mechanic
and chemical process), b) the role and function of oesophagus,
gaster, intestinum tenue and intestinum crassum in the
Expected Outcome
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
transport mechanism of nutrients and food blending process,

c) the digestion of carbohydrate, protein and fat, and d) basic
principles of water, electrolytes and nutrient absorption.
Explaining the physiology of hungry behaviour
Explaining and calculating the requirement of energy in
different life cycle, i.e. newborn (premature and aterm), infant,
childhood, adolescence, adulthood (including pregnant and
lactating mother) and geriatric
Explaining and calculating the requirement of nutrients (macroand micronutrients) in different life cycle, including a)
pregnancy and breastfeeding, b) neonates (premature and
aterm), infant and child, c) adolescence, d) adult, and e)
geriatric
Formatting daily human diet based on recommended dietary
allowance (RDA)
Applying knowledge on nutrition and metabolism to explain
certain popular diet, e.g. blood type diet, herbal diet, etc
Explaining different sources of nutrients from daily diet,
including a) macronutrients (lipid, carbohydrate and protein)
and b) micronutrients (vitamins [water- and fat-soluble
vitamins) and trace element [natrium, kalium, klorida, calcium,
iron and iodine])
Explaining the process of distribution, metabolism and
excretion of macro- and micronutrients in the human body
Explaining the body control (neuronal and hormonal) in
maintaining energy stability
Explaining the role of macronutrients in maintaining energy
stability
Explaining the role of micronutrients in the normal function of
the body
Explaining the composition of energy-source nutrients in
various types of dietary products
Explaining the concept of energy expenditure, including
expenditures for basal metabolism, activities and sickness
Explaining the association between nutritional intake and
social environment
Explaining the pathophysiology of macro- and micronutrients
deficiencies and excesses
Explaining the pathogenesis of macro- and micronutrients
deficiencies and excesses
21. Explaining the risk factor for acquiring nutritional disorders

(deficiencies and excesses)
22. Explaining the impact of acquiring nutritional disorders
(biological and non biological impact)
23. Measuring body weight, height, waist, arm circumference, and
head circumference
24. Explaining various laboratory measurement required to assess
nutritional status (lipid profile, haemoglobin, serum protein, etc)
25. Explaining the route of nutritional intake (enteral and
parenteral) in clinical settings
26. Explaining the principle that underlies the needs to perform
dietary adjustment (macro- and micronutrients) in organ and
metabolic disorders
27. Explaining the dietary composition (macro- and micronutrients)
for individual with organ and metabolic disorders
Tutorial
T U TOR I A L
The tutorial approach is developed based on the problem-based
learning (PBL) principle in which students are at the center.
Therefore, students themselves are responsible for their own
learning process. Students decide for themselves what they want to
learn and have considerable control over the choice of literature.
During the tutorials, they are divided into group of 10-12 students to
discuss a given problem using a procedure called the seven jump
approach. This approach is conducted in the following consecutive
phases, including:
Step 1: Clarifying unfamiliar terms
Step 2 : Problems definition
Step 3 : Brainstorm
Step 4 : Analyzing the problems
Step 5 : Formulating learning objectives
Step 6 : Self-study
Step 7 : Reporting
In general, the tutorial process for each case is conducted in two
group work. During the first group work, students will work in a
group for a give case until they come out with learning objectives
(step 5). After the first session, student will conduct self-study and
report their finding in the second session. Within the last 20
minutes of the second session, it is then continued with the
discussion of the next case (step 1 to 5). These processes are
repeated for the whole tutorials. During each week, students are
given sufficient time to consult with expert their difficulties in
understanding certain topics.
The problems discuss in the tutorial groups consist of 1) which food
do you prefer, delicious or healthy food?, 2) my first son, 3)
gastrointestinal tract function, 4) food passage in gastrointestinal
tract, 5) where does energy come from?, 6) micronutrients for the
normal functioning of human body, 7) dream of young obese, 8)
story of Rio, 9) folate deficiency, 10) osteoporosis and calcium
intake, 11) bedside teaching, and 12) will I survive over the next
year? These problems are addressed to cover all of the given

objectives/outcomes, except for medical and certain other skills
During the process, students have a number of roles to take, i.e.
one student acts as chair, another as scribe and the whole process
is supervised by a tutor. The chair and scribe are chosen randomly
and every student will get their turn to be the chair and scribe. Both
of them have important roles in maintaining the learning
atmosphere of the group.
Tutorial
SCENARIO 1: WHICH FOOD DO YOU PREFER, DELICIOUS OR
HEALTHY FOOD?
Many studies found that more than 80% of community-dwelling had
inadequate dietary intake of vitamin D and calcium. Vitamin B-12
deficiency is known to be prevalent in this population as well.
These conditions may be a consequence of hunger in certain
conditions which reduced dietary intake. Dietary supplements can
play an important role in moving individual closer to the
recommended levels. In order to fulfil this requirement, what kind of
nutrients is actually required by the body and where can one get
the nutrition from?
Learning objectives
1. Explaining different sources of nutrients from daily diet,
including a) macronutrients (lipid, carbohydrate and protein)
and b) micronutrients (vitamins [water- and fat-soluble
vitamins) and trace element [calcium, iron and iodium])
2. Explaining the composition of energy-source nutrients in
various types of dietary products
Reference
Sediaoetama, AD, 1993. Ilmu Gizi II. Dian Rakyat, Jakarta. Bab 4:
Pengetahuan Bahan Makanan, p79-140.
Rimbawan and Siagian, A, 2004. Indeks Glikemik Pangan: Cara
Mudah Memilih Pangan yang Menyehatkan. Penebar Swadaya,
Jakarta. Bab 3: Konsep Indeks Glikemik, p23-32.
Jakarta. Bab 4: Faktor-Faktor yang Mempengaruhi Indeks Glikemik
Pangan, p33-40.
Jakarta. Bab 9: Indeks Glikemik dan Makanan Seimbang, p91-96.
Jakarta. Lampiran, p103-112.
10
SCENARIO 2: MY FIRST SON

Mrs. Risa, a 25 year old woman, visited the community health
center (Puskesmas) to have an examination of her 1 month old
baby who is considered small for his age. From the history taking,
the doctor noticed that his birth weight is below normal (2400 g).
Mrs. Risa mentioned that she had severe vomit during the first
three months of her pregnancy. Moreover, her weight was not
appropriately increased during the pregnancy though she had
better appetite after the first trimester. After the delivery, she also
mentioned that her breast milk is less than expected and her baby
often cried. The doctor suggested her to pay more attention on her
nutrition as well as her baby by providing more nutritious food and
bottled milk if necessary. What underlies the doctors suggestion?
Does the body requirement actually difference in certain condition
and various stage of life?
Learning objectives:
1. Explaining and calculating the requirement of nutrients (macroand micronutrients) in different life cycle, including a)
pregnancy and breastfeeding, b) neonates (premature and
aterm), infant and child, c) adolescence, d) adult, and e)
geriatric
2. Explaining and calculating the requirement of energy in
different life cycle, i.e. newborn (premature and aterm), infant,
childhood, adolescence, adulthood (including pregnant and
lactating mother) and geriatric
Reference
Bowman, BA & Russell, RM, 2001. Present Knowledge in Nutrition,
8th edition. ILSI Press, Washington DC. Part 6: Nutrition and the
Life Cycle, p403-46.
American Dietetic Association, 2000. Manual of Clinical Dietetics,
6th edition. American Dietetic Association, Chicago, Illinois. Part 2:
Lifecycle Nutrition, p69-158.
Tutorial
SCENARIO 3: GASTROINTESTINAL TRACT FUNCTION
Gastrointestinal tract provides water, electrolytes & nutrients for the
body. The nutrients consist of macro- and micronutrients. Once
they enter the gastrointestinal tract, they will undergo a range of
digestion process. Each part of the gastrointestinal tract plays
different role in this digestion process which also requires the
alimentary secretion. A range of glands is available within the
alimentary tract to provide appropriate substrate to help the
digestion of food. This digestion process is controlled by a complex
neuronal and hormonal system. Moreover, gastrointestinal
vascularisation is also unique which is needed in transferring the
nutrients from the alimentary tract lumen into the vascular lumen.
1. Explaining the basic principle of gastrointestinal tract function,
including a) the motility of, b) the neurological and hormonal
control of, and c) blood flow regulation of gastrointestinal tract
2.
Explaining the secretory function of gastrointestinal tract,

including types and characteristics of gastrointestinal glands,
their secretion and roles, as well as factors influencing the
secretion.
References
Guyton, AC and Hall, JE, 2006. Textbook of Medical Physiology,
11th edition. Elsevier Saunders, Philadelphia. Chapter 62: General
Principles of Gastrointestinal Function Motility, Nervous Control,
and Blood Circulation, p771-80.
11th edition. Elsevier Saunders, Philadelphia. Chapter 63:
Propulsion and Mixing of Food in the Alimentary Tract, p781-90.
11th edition. Elsevier Saunders, Philadelphia. Chapter 64: Secretory
Function of the Alimentary Tract, p791-807.
Saladin, 2007. Anatomy & Physiology: The Unity of Form and
Function, 4th edition. McGraw Hill Co, New York. Chapter 25: The
Digestive System, p940-68 and p974-79.
12
SCENARIO 4: FOOD PASSAGE IN GASTROINTESTINAL

TRACT
Consumed foods will not be absorbed directly in the gastrointestinal
tract. They must be broken down into smaller components that are
universal to all species. Consider what will happen when someone
eats a piece of beef, for example. The myosin of beef differs very
little from that of his own muscles, but the two are not identical, and
even if they were, beef myosin could not be absorbed, transported
in the blood, and incorporated into his muscles. Like any other
dietary protein, it must be broken down into amino acids before it
can be used. Since beef and human proteins are made of the same
20 amino acids, those of beef proteins might indeed become part of
his own myosin but could equally well end up in his insulin,
fibrinogen, collagen, or any other protein. The digestive system
plays important role in this process. What is actually happened in
the gastrointestinal tract when foods enter it?
1. Explaining the digestion (mechanical & chemical) mechanism
of macro- and micronutrients in gastrointestinal tract.
2.
Explaining the absorption and transport mechanism of

nutrients (macro- and micronutrients) in gastrointestinal tract.
References
Brody, T, 1999. Nutritional Biochemistry, 2nd edition. Academic
Press, California. Part 2: Digestion and Absorption, p57-130.
Press, California. Part 3: Nutrients that Resist or Escape Digestion,
p133-53.
Propulsion and Mixing of Food in the Alimentary Tract, p781-90.
11th edition. Elsevier Saunders, Philadelphia. Chapter 65: Digestion
and Absorption in the Gastrointestinal Tract, p808-18.
Function, 4th edition. McGraw Hill Co, New York. Chapter 25: The
Digestive System, p968-73.
Tutorial
14
SCENARIO 5: WHERE DOES ENERGY COME FROM?
Nutrition is the starting point and basis for all human form and
function. From the time a single-celled, fertilized egg divides in two,
nutrition provides the matter needed for cell division, growth, and
development. It is the source of fuel that provides the energy for all
biological work and of the raw materials for replacement of wornout biomolecules and cells. The fact that it provides only the raw
materials means, further, that chemical change-metabolism-lies at
the foundation of form and function. Following the absorption in the
gastrointestinal tract, various nutrients will be used for different
purposes in the human body. Specifically for macronutrients, what
are their roles in the body? What will happen after theyre being
absorbed from the gastrointestinal tract?
1. Explaining the role of macronutrients in the normal functioning
of the body.
2.
Explaining the metabolism of circulated macronutrients.
Reference
Press, California. Part 4: Regulation of Energy Metabolism, p157261.
Metabolism of Carbohydrates, and Formation of Adenosine
Triphosphate, p829-39.
11th edition. Elsevier Saunders, Philadelphia. Chapter 68: Lipid
Metabolism, p840-48.
11th edition. Elsevier Saunders, Philadelphia. Chapter 69: Protein
Metabolism, p852-57.
Function, 4th edition. McGraw Hill Co, New York. Chapter 26:
Nutrition and Metabolism, p986-94 and p996-1007.
SCENARIO 6: MICRONUTRIENTS FOR THE NORMAL

FUNCTIONING OF HUMAN BODY
Micronutrients have been shown important for the normal
functioning of human body though they are required in a small
amount. Vitamin D, for instance, is required for the formation of
bones and teeth; iodine is one of the components in producing
thyroid hormone, etc.
After being absorbed from the gastrointestinal system, these
nutrients will be transferred, metabolized, stored and excreted from
the body. Iron, for instance, is absorbed in a small amount in
duodenum and jejunum and then bound with plasma transferrin in
the blood in the form of ferrous. Ferrous is necessary in the
production of red blood cells. Iron is also stored in large amounts in
the body. It is stored in a protein called ferritin.
Considering the fact described above, what are the role of
micronutrients (vitamins and trace elements) for human body? Can
these nutrients be used directly after being absorbed from the
alimentary tract?
1. Explaining the role of micronutrients, i.e. vitamins (fat- and
water-soluble vitamins) and trace elements (iron, iodine,
calcium, sodium, potassium, and chloride), in the normal
functioning of the body.
2.
Explaining the metabolism of circulated micronutrients.
Reference
11th edition. Elsevier Saunders, Philadelphia. Dietary Balances;
Regulation of Feeding; Obesity and Starvation; Vitamins and
Minerals, p875-80.
8th edition. ILSI Press, Washington DC. Part 3: Fat-Soluble
Vitamins, p127-164.
Tutorial
8th edition. ILSI Press, Washington DC. Part 4: Water-Soluble
Vitamins, p127-72.
8th edition. ILSI Press, Washington DC. Chapter 26: Calcium, p273280.
8th edition. ILSI Press, Washington DC. Chapter 29: Sodium,
Chloride, and Potassium, p302-10.
8th edition. ILSI Press, Washington DC. Chapter 30: Iron, p311-328.
8th edition. ILSI Press, Washington DC. Chapter 32: Iodine and the
Iodine Deficiency Disorders, p344-351.
16
SCENARIO 7: DREAMS OF YOUNG OBESE

Daily intake of food is necessary to maintain homeostasis, supply
energy and permit growth. Energy demands vary depending on
activity, environment and physiologic state of individual.
Macronutrients are the main sources of energy. Excessive amount
of macronutrient intakes may lead to over nutrition. Meanwhile
consuming less macronutrient may provoke glicolysis process to
maintain sufficient amount of required energy.
An obese young woman, 24-year-old, with 188 cm height and 132
kg weight provided an example of imbalance between intake and
energy expenditure. She has continuously consumed calorie-dense
food with minimal physical activity. Looking at her body, she really
wants to stop eating and do something to make her body more
proportional. Looking at condition, what is actually determined
individual feeding behaviour?
1. Explaining the concepts of energy expenditure, including basal
metabolism, growth and development, activities, and
expenditure during sickness.
2. Explaining the regulation of feeding.
3.
Explaining the association between nutritional intake and

social environment.
Reference
Bowman, BA, and Russell, RM, 2001. Present Knowledge in
Nutrition, 8th edition. ILSI, Washington DC. Chapter 1: Energy
Metabolism, p3-12.
Nutrition, 8th edition. ILSI, Washington DC. Chapter 2: Exercise,
p22-30.
Nutrition, 8th edition. ILSI, Washington DC. Chapter 4: Regulation of
Energy Intake Factors Contributing to Obesity, p31-41.
Tutorial
Press, California. Part 4: Regulation of Energy Metabolism, p157261.
Press, California. Part 5: Energy Requirement, p273-307.
11th edition. Elsevier Saunders, Philadelphia. Chapter 72: Energetic
and Metabolic Rate, p881-88.
11th edition. Elsevier Saunders, Philadelphia. Chapter 71: Dietary
Balances; Regulation of Feeding; Obesity and Starvation; Vitamins
and Minerals, p867-71.
18
SCENARIO 8: STORY OF RIO

A 1.5 year-old boy was presented to a general practitioner with
complaints of low body weight. Her mother gives him 4-5 spoon
rice porridge per day, sometimes rice and half a cup of sweet tea.
Tempe, tofu or boiled egg is given once a week. Anthropometric
examination found that his height was 82 cm and weight 7200
grams. Further physical examination showed sign of chest
retraction, prominent ribs and ascites. Moreover, reductions of
blood glucose and plasma albumin levels were prominent
laboratory findings. From these findings, his physician expressed
that Rio had severe malnutrition.
The above example underlines macronutrient deficiency syndrome.
What will happened if one consumes excessive amount of
macronutrients?
1. Explaining the macronutrient deficiencies syndrome (risk
factors, impact, and clinical and laboratory findings).
2.
Explaining the consequences, risk factors, and clinical and

laboratory findings of excessive macronutrient intake.
Reference
6th edition. American Dietetic Association, Chicago Illinois. Part 1:
Nutrition Assessment, p3-67.
6th edition. American Dietetic Association, Chicago Illinois. Chapter
23: Obesity, p365-386.
WHO, 1999. Management of Severe Malnutrition: A Manual for
Physicians and Other Senior Health Workers.
Tutorial
20
SCENARIO 9: FOLATE DEFICIENCY

Folate deficiency occurs in pregnancy on a wide scale. The
increased utilization of the vitamin by the fetus and related tissues,
as well as the secretion in milk during lactation, can place an
increased demand on the dietary folates consumed by the mother.
Severe folate deficiency leads to megaloblastic anemia. This
disease, in which the synthesis of red blood cells is impaired, tends
to occur with pregnancy in underdeveloped countries, but usually
not in North America or Europe. Goats milk is a poor source of
folate and vitamin B12. Overreliance on goats milk as a source of
food for infants can result in a deficiency in these vitamins and in
anemia. Apart from folate deficiency, what will happen if one
experience deficiency of other vitamins? When an individual
consumed rigorous amount of vitamins, what will happen?
1. Explaining vitamin deficiencies syndrome (risk factors, impact,
and clinical and laboratory findings).
2.

laboratory findings of excessive vitamins intake.
Reference
Nutrition, 8th edition. ILSI, Washington DC. Part 3: Fat-Soluble
Vitamins, p127-173.
Nutrition, 8th edition. ILSI, Washington DC. Par 4: Water-Soluble
Vitamins, p175-271.
Press, California. Part 9: Vitamins, p491-692.
SCENARIO 10: OSTEOPOROSIS AND CALCIUM INTAKE

It is estimated that at least 15 million person in the United States
have osteoporosis. The sites of osteoporotic fractures most
commonly are the vertebra and hip, though the forearm and wrist
are also involved. A bone fracture in an elderly person is
undesirable because it leads to periods of disability. In addition,
about 10% of the fractures of osteoporosis are fatal. Osteoporosis
results from the continued activity of osteoclasts but reduced
activity of osteoblasts. Hence the disease involves a lack of
coordination in the rates of bone resorption and formation.
Calcium nutrition and physical activity are contributing factors in
maintaining skeletal mass. It is firmly established that the loss of
bone and a negative calcium balance tend to occur throughout the
population after the age of 40. It is also obvious that a dietary
deficiency in calcium leads to progressive bone losses.
When there is excessive intake of calcium, what will happen? Other
than calcium, what are the consequences of imbalance between
intake and requirement of sodium, potassium, chloride, iron, and
iodine?
1. Explaining trace element deficiencies syndrome (risk factors,
impact, and clinical and laboratory findings).
2.

laboratory findings of excessive trace elements intake
Reference
Nutrition, 8th edition. ILSI, Washington DC. Chapter 26: Calcium
Deficiency, p277-279.
Tutorial
Nutrition, 8th edition. ILSI, Washington DC. Chapter 29: Sodium,
Chloride, and Potassium, p302-310.
Nutrition, 8th edition. ILSI, Washington DC. Chapter 30: Iron, p318320, 323-324.
Nutrition, 8th edition. ILSI, Washington DC. Chapter 32: Iodine and
the Iodine Deficiency Disorders, p346-347, 349.
Nutrition, 8th edition. ILSI, Washington DC. Chapter 51:
Osteoporosis, p564-72.
Press, California. Part 10: Inorganic Nutrients, p721-30; p736-38;
p755-60; and p765-94.
22
SCENARIO 11: BEDSIDE TEACHING

Doctor
Marsono
Doctor
:
:
Student
Doctor
Good Morning Mr. Marsono. I would like to introduce our you

doing internship in this hospital. Do you mind if I discuss your
No, be my guest doctor. We need young doctors in the future
Thank you Mr. Marsono. OK lets get started then. We all kno
requirement is largely depend on his anthropometric characte
climate and also the normal function of body organs. For exam
56 year-old and has been suffering from chronic renal failure
Currently he had undergone hem dialysis. When admitted to
delirium and profuse vomit. We gave him parenteral diet for a
followed by enteral diet. Since he has renal disorder, we mak
for instance, by lowering the protein intake.
Im sorry to interrupt doctor, is it mandatory to make adjustm
whenever he had renal disorder? Are there any other conditio
adjustment of dietary intake?
Certainly. Most organ disorders require dietary adjustment, fo
liver and kidney. We shall discuss this topic later in the class.
1. Explaining the route of nutritional intake (enteral and
parenteral) in clinical settings.
2.
Explaining the principles of diets in patients with organ

disorders (heart, ren and liver disorders).
References:
Nutrition, 8th edition. ILSI, Washington DC. Chapter 44: Nutrition
and Liver Disease, p483-96.
Nutrition, 8th edition. ILSI, Washington DC. Chapter 46: Nutrition
and Kidney Disease, p508-16.
Tutorial
Nutrition, 8th edition. ILSI, Washington DC. Chapter 49:
Atherosclerotic Cardiovascular Disease, p543-51.
29: Liver Disease, p415-20.
16: Cardiac Surgery, p257-58.
17: Congestive Heart Failure, p259-62.
6th edition. American Dietetic Association, Chicago Illinois. Part 3:
Renal Disease, p449-502.
48: Nutrition Support, p589-649.
SCENARIO 12: WILL I SURVIVE OVER THE NEXT YEAR?
24
Mr. Rudi, 56 years old, visited a clinic as part of his routine

treatment for diabetes and hypertension in which he has been
suffering for the last 2 years. His weight was 78 kg with 160 cm
height. The laboratory examination showed high concentration of
blood glucose and lipids. He also noticed that Mr. Rudi didnt follow
the recommended dietary plan for the last 2 months despite taking
his medicine regularly. The doctor advised him to follow the
recommended dietary plan to help him controlling the
progressiveness of both hypertension and diabetes.
Explaining the principles of diets in patients with metabolic
disorders (diabetes, hypertension and hyperlipidemia).
Reference
Nutrition, 8th edition. ILSI, Washington DC. Chapter 50: Diabetes
Mellitus, p552-63.
18: Hyperlipidemia, p265-90.
19: Hypertension, p291-300.
20: Diabetes Mellitus, p301-36.
Evaluation
26
E v a lu a t i o n
The evaluation of student achievement during the metabolism and
energy block consist of three components: 1) overall block
achievement, 2) medical skill performance, and 3) medical
research capability. The following table summarizes the contribution
of these components in students final mark as well as categories
assessed in each component.
Component of
assessment
Overall block
achievement
Medical skill
vein puncture
Medical
research
capability
Score
percentag
e
92.5%
Categories assessed
Attendance and
disciplinary
Laboratory work
Performance in
nutritional assessment
Student assignment
Analysis of
popular diet
Case study
Final examination
Oral examination
Written
examination
Score
percentag
e
2.5%
5%
12.5%
10%
20%
80%
70%
20%
80%
2.5%
5%
Among assessment methods described above, tutors particularly

play important role in 1) assuring students attendance and
disciplinary, 2) assessing students performance during oral
examination, and 3) developing part of the questions used for
written examination.
Students that attend all session on time (maximum tolerance time
15 minute) will be granted 2.5% of overall block achievement score.
This attendance is also one of the pre-requisite of following final
examination, both oral and written examinations.
Oral examination will be conducted for 30 minutes for each student.

Tutors will act as the assessor. Each assessor will be equipped with
a list of questions and expected answers in a checklist format as
part of the assessment tool. The aim is to assess students
understanding regarding the concept applied in this block. Each
student will be given a case related to the expected exit outcome of
the block. After reading the scenario, students will be asked to
provide general overview on the topic and followed with discussion
session with assessor.
Written examination constitutes as the largest proportion in the
overall block achievement. This examination will provide
information regarding students general understanding of the
concept applied in this block. Multiple choice questions (MCQ) with
vignette are at the heart of it.
28
Reference
Reference
6th edition. American Dietetic Association, Chicago Illinois.
8th edition. ILSI Press, Washington, DC.
Press, California.
11th edition. Elsevier Saunders, Philadelphia.
Jakarta.
Function, 4th edition. McGraw Hill Co, New York.
Sediaoetama, AD, 1993. Ilmu Gizi II. Dian Rakyat, Jakarta.
WHO, 1999. Management of Severe Malnutrition: A Manual for
Physicians and Other Senior Health workers.
Tim e Tab l e
Monday, April 13th, 2009
07.30 08.20
Introduction lecture
08.30 10.20
Lecture: The anatomy of gastrointestinal tract
13.30 15.10
Laboratory work: Gastrointestinal tract anatomy
Tuesday, April 14th, 2009
08.30 10.20
Lecture: Anthropometric measurement
10.30 11.20
Lecture: Transport mechanism of nutrients, water
and electrolytes in gastrointestinal tract
13.30 15.10
Wednesday, April 15th, 2009
08.30 10.20
Tutorial: Scenario 1
10.30 11.20
Lecture: The histology of gastrointestinal tract and
its accessory glands
13.30 15.10
Thursday, April 16th, 2009
08.30 09.20
Lecture: Medical research
09.30 10.20
Lecture: Vein puncture
Friday, April 17th, 2009
08.00 09.40
Tutorial: Scenario 1 and 2
10.00 10.50
Pleno session: scenario 1
Saturday, April 18th, 2009
08.00 12.20
Open laboratory: The histology of gastrointestinal
tract
08.30 10.20
10.30 11.20
Lecture: Neurological and hormonal control of
gastrointestinal tract
Tuesday, April 21st, 2009
10.30 12.20
Medical skill laboratory: Demonstration of
anthropometric measurement and vein puncture
Wednesday, April 22nd, 2009
08.30 10.20
10.30 12.20
Lecture: Overview of essential nutrient
metabolism
Time
30 Table
Thursday, April 23rd, 2009
08.30 09.20
10.30 12.20
Medical skill laboratory: Anthropometric
measurement and vein puncture
Friday, April 24th, 2009
08.00 09.40
10.00 10.50
Pleno session: scenario 2-4
Saturday, April 25th, 2009
08.00 12.20
tract
08.30 10.20
10.30 12.20
Lecture: Basic Principles of human dietary intake
12.30 13.20
Student assignment: A thorough overview of
popular diet from medical nutrition perspective
Tuesday, April 28th, 2009
10.30 12.20
Wednesday, April 29th, 2009
08.30 10.20
Thursday, April 30th, 2009
08.30 09.20
10.30 12.20
Friday, May 1st, 2009
08.00 09.40
10.00 10.50
Saturday, May 2nd, 2009
08.00 12.20
tract
Monday, May 4th, 2009
08.30 10.20
10.30 12.20
Lecture: Laboratory measurements to assess
nutritional status
Tuesday, May 5th, 2009
10.30 12.20
Wednesday, May 6th, 2009

08.30 10.20
Thursday, May 7th, 2009
08.30 09.20
10.30 12.20
Friday, May 8th, 2009
08.00 09.40
10.00 10.50
Monday, May 11th, 2009
08.30 10.20
11.30 12.20
Lecture: Drug and food interaction
Tuesday, May 12, 2009
10.30 12.20
08.30 10.20
Tutorial: Scenario 12
08.30 09.20
10.30 12.20
09.30 12.00
Mini seminar 1:
09.30 12.00
Mini seminar 2:
Thursday, May 21st, 2009
08.30 09.20
10.30 12.20

Friday, May 22nd, 2009

09.30 10.20
Final wrap up session
Monday, May 23rd, 2009
08.00 11.00
Oral examination
13.30 15.00
Anatomy laboratory examination
Time
32 Table
08.00 11.00
Oral examination

08.00 09.00
Written examination
08.00 11.00
Skill evaluation

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M a

Metabolism and energ y

Time Table ______________________________________

Inside the human body

Where can people get required nutrients from?

What will happen when food enters the gastrointestinal tract?

What are the roles of nutrients for normal individual?

Will the requirement differs in various stages of life?

1 Almatsier, S, 2002. Prinsip dasar ilmu gizi. Jakarta: PT Gramedia

Have completed block 1, 2, 3 and 4

Didnt fail more than 2 previous blocks

2.5. Explaining common health promotion and preventive

Explaining the anatomy of gastrointestinal tract and its related

transport mechanism of nutrients and food blending process,

21. Explaining the risk factor for acquiring nutritional disorders

year? These problems are addressed to cover all of the given

SCENARIO 2: MY FIRST SON

Explaining the secretory function of gastrointestinal tract,

SCENARIO 4: FOOD PASSAGE IN GASTROINTESTINAL

Explaining the absorption and transport mechanism of

Explaining the metabolism of circulated macronutrients.

SCENARIO 6: MICRONUTRIENTS FOR THE NORMAL

Explaining the metabolism of circulated micronutrients.

SCENARIO 7: DREAMS OF YOUNG OBESE

Explaining the association between nutritional intake and

SCENARIO 8: STORY OF RIO

Explaining the consequences, risk factors, and clinical and

SCENARIO 9: FOLATE DEFICIENCY

Explaining the consequences, risk factors, and clinical and

SCENARIO 10: OSTEOPOROSIS AND CALCIUM INTAKE

Explaining the consequences, risk factors, and clinical and

SCENARIO 11: BEDSIDE TEACHING

Good Morning Mr. Marsono. I would like to introduce our you

Explaining the principles of diets in patients with organ

SCENARIO 12: WILL I SURVIVE OVER THE NEXT YEAR?

Mr. Rudi, 56 years old, visited a clinic as part of his routine

Among assessment methods described above, tutors particularly

Oral examination will be conducted for 30 minutes for each student.

Wednesday, May 6th, 2009

Medical skill laboratory: Anthropometric

Friday, May 22nd, 2009

Wednesday, May 25th, 2009

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