Students Guidebook

Block V: METABOLISM & ENERGY

5th edition 2012

Contributors: Seto Priyambodo Ardiana Ekawanti Hadian Rahman Ida Ayu Eka Widiastuti Maulid Hidayat Monalisa Putu Aditya Raehan Bahraen Wahyu Sulstiya Affarah Dewi Suryani Marie Yuni Andani Yunita Sabrina

Fakultas Kedokteran Universitas Mataram

M et a b ol i sm a n d e n er g y

Students Guidebook
5th Edition 2012

Block coordinator:

dr. Seto Priyambodo , M.Sc

Contributor:

Seto Priyambodo Ardiana Ekawanti Hadian Rahman Ida Ayu Eka Widiastuti Maulid Hidayat Monalisa Putu Aditya Raehan Bahraen Wahyu Sulstiya Affarah Dewi Suryani Marie Yuni Andani Yunita Sabrina

Fakultas Kedokteran Universitas Mataram

P r ef a c e
Sufficient amount of nutrients are required by an individual to stay healthy. Human body cannot synthesize all of the required nutrients; therefore individuals always need to consume an adequate and appropriate food. The process in which nutrient from food could be utilized by cells and tissues requires several process: digestion, absorption, metabolism and utilization. Students are expected to 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 the core 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 acquisition of new knowledge and skills is largely depended on students activities. This guidebook is developed to assist students during their study in this block. We realize that this guidebook has some limitations. Therefore, suggestions and comments would be well appreciated.

Mataram, March 2012 Vice Dean I

Dr. Doddy Ario Kumboyo, Sp.OG (K) NIP. 195204091980031010

Table of Contents Introduction _______________________________________________________________ Expected Outcomes ________________________________________________________ Learning Strategies ________________________________________________________ Evaluation ________________________________________________________________ Referrence _______________________________________________________________ Annex 1: Scenario _________________________________________________________ Annex 2: Time Table _______________________________________________________ 12 11 9 6 3 1

Fakultas Kedokteran Unram

In t r o d u ct io n
Block Name: Metabolism and Energy A human adult eat tons of food each year. Metabolism and Energy block attempts to answer the question why by emphasizing on the concept of digestion, metabolism and utilization of nutrients to fulfill human body requirement. As seen in figure 1, mass flows of nutrient undergo several processes: digestion, metabolism and utilization. Digestion processes consist of mechanical digestion, chemical transformation and nutrient absorption in gastrointestinal tract. After being absorbed, nutrients are converted into energy, heat and specific body component by several chemical transformation processes. These products are then used for growth and development, repair of tissue damage, basal metabolism and activities. The remaining nutrients are put as deposit in certain part of the body. In individual with certain health status, the nutrient requirement will be different. More energy may be required to fulfill high metabolism processes while some other products are required to repair tissue damage.

Nutritional input

Food composition Requirement Meal size Food origin Mechanical digestion Chemical transformation Nutrient absorption
Interconversions of absorbed monomers Anabolic reactions (Synthesis of body specific components) Catabolic reactions (Energy / ATP or Heat) Formation of excretion products (waste) Inside human body 1|P a ge Basal metabolism Growth and development Tissue repair Nutrient deposit Activity Health status

Digestion

Metabolism

Physiological output

Figure 1. Conceptual basis for understanding nutrition and metabolism

Fakultas Kedokteran Unram

During this block, students need to understand the concept illustrated above in depth and link it with several clinical settings, i.e. nutritional, organ and metabolic disorders. To facilitate this understanding, two major themes are applied in this block, including 1) nutrition for normal individual well-being, and 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 such as essential amino acids, water-soluble and fat-soluble vitamins, minerals, and the essential fatty acids. The body also requires an adequate energy substrate, metabolizable carbohydrate, indigestible carbohydrate (fiber), additional nitrogen, and water. The requirement of nutrients varies 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. In order to fulfill an 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 being excreted. The balance between intake and utilization is necessary to ascertain normal functioning of the body.
1

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

2|P a ge

Fakultas Kedokteran Unram

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 a decrease or increase of excretion, detainment of nutrients in the blood vessels, etc. The second theme will provide the basis 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 Did not fail in more than 2 previous blocks

E xp e ct e d O u t c o m e
After completing 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 a long life learning, and 5) to communicate effectively with colleagues and other professionals. In order to achieve this outcome, students should master the following constructs: 1. Nutrition for normal individual wellbeing 1.1. Explaining the anatomy, physiology and histology of digestive system in providing nutrients and maintaining energy stability. 1.2. 1.3. 1.4. 1.5. Explaining the principles of human diet (source and metabolism of nutrient). Explaining the nutritional requirement in different lifecycle. Explaining the concept of energy stability, energy production and expenditure. Able to collect and apply basic interpretation skills in a given data regarding diet (secondary data) to validate scientific information systematically. 1.6. 1.7. 1.8. Able to use data and scientific evidence in approaching individual dietary plan. Performing anthropometric measurements to assess nutritional status. Identifying, deciding, and determining appropriate laboratory measurement to assess nutritional status.
3|P a ge

Fakultas Kedokteran Unram

2. Nutritional disorders 2.1. Explaining the pathogenesis and pathophysiology of nutritional disorders (nutrient deficiencies and excessive syndromes). 2.2. 2.3. 2.4. Explaining the effect of non biological factors related to nutritional disorders. Explaining the principles of drug and food interaction on gastrointestinal tract. Interpreting and explaining clinical and laboratory data to determine the diagnosis of nutritional disorders. 2.5. Explaining common health promotion and preventive approaches related to community nutrition.

3. Organ disorders 3.1 3.2 3.3 Explaining the principles of dietary treatment for patient with organ and metabolic disorders. Exploring and recording clearly dietary plans for patients with organ and metabolic disorders. Explaining and deciding when to give parenteral and enteral dietary route

4. Long live learning 4.1 4.2 Developing capability to be updated with scientific and technological advancement. Critically analyze medical literature and appropriately applied to students patient.

5. Ethics, moral and profesionalism 5.1 5.2 5.3 5.4 Appreciating others without preferences in certain personal status. Presenting a case clearly and efficiently. Constructively responding other people opinions 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. Explaining the anatomy of gastrointestinal tract and its related apparatus and glands 2. Explaining the histology of gastrointestinal tract 3. Explaining the basic principle of gastrointestinal tract function, including a) the motility, b) the neurological and hormonal control, and c) blood flow regulation of gastrointestinal tract

4|P a ge

Fakultas Kedokteran Unram

4. 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. 5. Explaining the transport and absorption mechanism nutrition in gastrointestinal tract, including a) digestion process (mechanic and chemical process), b) the role and function of esophagus, gaster, intestinum tenue and intestinum crassum in the 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. 6. Explaining the physiology of hungry behavior 7. 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 8. Explaining and calculating the requirement of nutrients (macro- and 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 9. Formatting daily human diet based on recommended dietary allowance (RDA) 10. Applying knowledge on nutrition and metabolism to explain certain popular diet, e.g. blood type diet, herbal diet, etc 11. 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]) 12. Explaining the process of distribution, metabolism and excretion of macro- and micronutrients in the human body 13. Explaining the body control (neuronal and hormonal) in maintaining energy stability 14. Explaining the role of macronutrients in maintaining energy stability 15. Explaining the role of micronutrients in the normal function of the body 16. Explaining the composition of energy-source nutrients in various types of dietary products 17. Explaining the concept of energy expenditure, including expenditures for basal metabolism, activities and sickness 18. Explaining the association between nutritional intake and social environment 19. Explaining the pathophysiology of macro- and micronutrients deficiencies and excesses 20. Explaining the pathogenesis of macro- and micronutrients deficiencies and excesses 21. Explaining the risk factor for acquiring nutritional disorders (deficiencies and excesses)
5|P a ge

Fakultas Kedokteran Unram

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, hemoglobin, serum protein, etc) 25. Explaining the route of nutritional intake (enteral and parenteral) in clinical settings 26. Explaining the basic principles of oral drug administration, including a) types, and b) the mechanism of food and drug interaction 27. Providing examples of drugs that interact in the gastrointestinal tract 28. Explaining the principle that underlies the needs to perform dietary adjustment (macro- and micronutrients) in organ and metabolic disorders 29. Explaining the dietary composition (macro- and micronutrients) for individual with organ and metabolic disorders

L e ar n in g S t r at eg ie s
Strategies used to deliver educational materials in this block consist of tutorials, lecturers, laboratory works, and students assignments. Tutorial with problem based approach is the heart of the learning strategy. Other strategies are required to complete student understanding on a given problem/topic. A. Tutorials 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

6|P a ge

Fakultas Kedokteran Unram

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 given case until they come out with learning objectives (step 5). After the first session, student will conduct a self-study and report their finding in the second session. 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) vacation to Bali, 2) my second pregnancy, 3)old baby, 4) diet oh diet, and 5) Mama Mias problem. These problems are addressed to cover all of the given objectives/outcome, except for medical and certain other skills. During the process, students have a number of roles to take, i.e. one student acts as a chair, another as a scriber and the whole process is supervised by a tutor. The chair and scriber are chosen randomly and every student will get their turn to be the chair and scriber. Both of them have important roles in maintaining the learning atmosphere of the group. B. Lecturers Lecturer provides fundamental knowledge on certain aspect in metabolism and energy and enhances students understanding on difficult topics further. Overall, lecture represents 12% of all educational processes. The following topics are given during lecturers: The anatomy of gastrointestinal tract The histology of gastrointestinal tract and its accessory glands Neurological and hormonal control of gastrointestinal tract Transport mechanism of nutrient, water and electrolytes in gastrointestinal tract Overview of nutrients metabolism Basic principles of human dietary intake Laboratory tests for nutritional disorders (syndrome deficiency or excessive of nutrients) Food supplementation and fortification Drug and food interaction Beside the above topics, there are four other lectures on medical research and statistics, i.e. 1) probability, 2) research subject, unit analysis and sampling, 3) research variables, and 4) sample size measurement.

7|P a ge

Fakultas Kedokteran Unram

C. Laboratory works In order to prove a better understanding regarding to metabolism and energy, students will be provided with four laboratory works in this block. These laboratories include histology, anatomy, and medical skill laboratories. The anatomy laboratory is required to enhance students understanding on gastrointestinal anatomy. Students will be divided into three groups and undergo two sessions of laboratory work. The histology laboratory is required to enhance students understanding on gastrointestinal histology and accessory glands. Students will be divided into three groups. Skills laboratory will provide students with skills in performing anthropometric measurements and vein puncture. The following methods will be used during students laboratory work, including lecture, demonstration, structured and self exercise on anthropometric measurement, vein and arterial puncture. D. Student assignment Overall, there are two assignments in this block, journal reading and case-study. Students will work in a group of 10-12 persons for both assignments. Journal reading In this assignment, certain journal will be provided for each group of students. The students will analyze the content of the journal according to scientific writing procedure. Analysis should be made from the medical nutrition perspective. The case will be provided during the third week of the block. The essay is written in A4 paper, with arial font, 11 points, and 1.5 cm space. The essay should have been completed and handed to the following email address: setopriyambodo97@gmail.com

Case study: individual nutrition in certain clinical conditions Each group will conduct a visit to instalasi gizi of NTB Province General Hospital. During the visit, student should collect relevant information on a given case. Students will be guided for nutritional visit to the patients by a dietician and attend nutritional outpatient polyclinic. The cases consist of 1) nutrition in pregnancy, 2) nutrition for children under five, 3) nutrition for patient with metabolic disorders, 4) nutrition for patient with organ disorder, and 5) nutrition for the elderly. This assignment is addressed to provide students capabilities in 1) collecting, analyzing, and interpreting information related to nutrition in clinical setting, 2) applying knowledge on nutrition in certain clinical setting, and 3) performing appropriate case presentation skill.
8|P a ge

Fakultas Kedokteran Unram

Following the visit, student will then analyze the case from the medical nutrition perspective. The result of the study will be presented in mini seminar attended by relevant expertise. Written report shall be provided and collected on line to the following email address setopriyambodo97@gmail.com

The following experts shall attend the seminar, including dietician, pediatrician, obstetrician, and internist. They will provide feedback on students presentation and assess the presentation using a given assessment tool. Final mark of this case study will be determined based on the presentation (40%) and written report (60%).

E v al u at 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 Tutorial assessment Laboratory work Student assignment Jurnal reading Case study Score percentage 2.5% 7.5% 5% 40% 60% 70% 20% 70% 10% 15 % 50% 50%

Final examination Oral examination Written examination CBT

Medical skill Vein puncture anthropometry

Students that attend all session on time (maximum tolerance time 15 minute) will be granted with 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.

9|P a ge

Fakultas Kedokteran Unram

Practical examination will be provided for anatomy and histology laboratory. The assessment consists of a set of questions pointed on specific part of human gastrointestinal tract. The aim is to explore students knowledge on gastrointestinal tract anatomy and histolgy. In this blok, medical skill performance, particularly anthropometric measurement skills, will be assessed. Scenarios will be given and students are asked to perform appropriate anthropometric examination and vein puncture procedure. Standardized checklist is used to assess students performance along with OSCE to assess students skill. Both students assignments will be assessed using standardized checklist. Tutors of the block shall act as the assessor. Specifically for case study, students final mark comes from both presentation and written report. Standardized checklists will be developed to include students presentation and scientific written skill, as well as understanding on a given topic. Oral examination will be conducted for 15 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 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 Computer Based Test (CBT) will be conducted for prepar ing the students to U KDI. It consist o f 10% of final exa mina tion proportion . The e x a m i n a t i o n w i l l b e h e l d i n c o m p u t e r l a b o r a t o r y . Multiple choice questions (MCQ) with vignette are also at the heart of it.

10 | P a g e

Fakultas Kedokteran Unram

R ef er e n ce
American Dietetic Association, 2000. Manual of Clinical Dietetics, 6th edition. American Dietetic Association, Chicago Illinois. Baynes and Dominickzak, 2003. Medical Biochemistry. Mosby Co, Singapore. Bowman, BA & Russell, RM, 2001. Present Knowledge in Nutrition, 8th edition. ILSI Press, Washington, DC. Brody, T, 1999. Nutritional Biochemistry, 2nd edition. Academic Press, California. Guyton, AC and Hall, JE, 2006. Textbook of Medical Physiology, 11th Philadelphia. Harkness, R, 1984. Interaksi Obat. Penerbit ITB Bandung, Bandung. Hoffer, LJ, 2001. Clinical Nutrition: Protein-energy malnutrition in the in patient. CMAJ, 165:10. Jones, JP, 2002. Clinical Nutrition: Functional Food. CMAJ, 166:12. Melmon and Morrelis, 2000. Clinical Pharmacology, 4th edition. McGraw Hill, New York. Montgomery, et al, 1993. Biochemistry. Mosby Co, Singapore Moore, KL & Dalle, AF, 2006. Clinically Oriented Anatomy, 5th edition. Lippincott Williams & Wilkins, Philadelphia. Murray, et al, 2003. Biokimia Harper, ed 25. EGC, Jakarta. Pi-Sunyer,FX, 2000. Over nutrition and Under nutrition as Modifiers of Metabolic Processes in Disease States. Am J Clin Nutr; 72 (suppl): 533S-7S. Saladin, 2007. Anatomy & Physiology: The Unity of Form and Function, 4th edition. McGraw Hill Co, New York. Sediaoetama, AD, 1993. Ilmu Gizi I. Dian Rakyat, Jakarta. Setiawati, A, 2005. Farmakologi Dasar dan Klinik. Balai Penerbit FK UI, Jakarta. UNICEF, 1991. Strategy for improved nutrition of children and women in developing countries. UNICEF policy review, New York. WHO, 1999. Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health workers. Wilson, et al, 1991. Harrisons Principles of Internal Medicine. Mc-Graw Hill Co, New York Wiryo, H, 2004. Malnutrisi Berat: Patofisiologi, Penilaian, Pengobatan, Rehabilitasi dan Follow up. UPT Mataram University Press, Mataram.
11 | P a g e

edition. Elsevier Saunders,

Fakultas Kedokteran Unram

An n ex 1. S c en ar i o
SCENARIO 1: TRIP TO LOMBOK. Awaited day has come. Two best friends, Raehan and Fauzy will go to Lombok in a vacation for the first time. They take public water transport Ferry from Padang Bai Harbor to Lembar Harbor. Early in the morning before the trip, Raehan has a full serve breakfast, rice and chicken soup. Meanwhile, Fauzy choose not to eat anything but a glass of fresh water to avoid bowel movement and urge of defecation during the trip. Fauzy often has a bowel movement which urge him to defecate after meal since he didnt defecate regularly. After about two hours trip, the two buddies suffered seasick. Raehan tells Fauzy that he has vomited out all his breakfast, included pieces of chicken in his soup which still can be discerned. The vomit smelled sour and gave him a sore throat. Conversely, Fauzy only gave out water and saliva. Arriving at Lembar after 5 hours of sea trip, unbearable hunger leads them to Sate Bulayak stall. While waiting for the meal ready to serve, their stomach were rumbling and they were swallowing their saliva occasionally.

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. Guyton, AC and Hall, JE, 2006. Textbook of Medical Physiology, 11th edition. Elsevier Saunders, Philadelphia. Chapter 63: Propulsion and Mixing of Food in the Alimentary Tract, p781-90. Guyton, AC and Hall, JE, 2006. Textbook of Medical Physiology, 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 | P a g e

Fakultas Kedokteran Unram

SCENARIO 2: MEDICAL STUDENT ASSIGNMENT

Desta and Gisell, two student in medical Faculty, their lecturer gived them a task to make summary of daily nutrition and energy requirement each of family member in their home. Desta lives with his father, mother, grandfather and younger sister in home. Desta is 19 years old now, his younger Sister is 13 years old, his father and mother are 40 years old and his grandfather is 63 years old. Desta usually plays futsal after finished his campus activity in the afternoon. his grandfather commonly does daily activities by gardening and reading newspaper. His mother has bad problem with her weight body because [of overweight] her body is very big. Meanwhile his grandfather appears more skinny. Meanwhile, Gisell lives with her older brother, her sister in-law, and two nephews each of them four years old and eleven months. her sister in-law was pregnant now and her old nephew was sick since two days ago, he has got fever and have to get bedrest. Could tou help Gisell and Desta to make summary of daily nutrition and energy requirement each of their family member?

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. UNICEF, 1991. Strategy for improved nutrition of children and women in developing countries. UNICEF policy review, New York.

SCENARIO 3: How do I will be skinnier?

13 | P a g e

Fakultas Kedokteran Unram

Roni is a senior high school student, and now he is in the last year. When he was a young boy he had a dream to be a policeman. Unfortunately, after he knew that becoming a policeman need specific requirements including an ideal body weight. Therefore, he was unable to apply for the police academy this year. Based on the last antrophometric examination 3 month ago his body weight was 90 kg and height 168 cm, thus his nutritional status was obese. From now on, he has a program to decrease his BW by changing some of his habbit . He consumes fast food and chocolate almost everyday. Fast food predominantly contain carbohydrate and fat. He read from an article in the newspaper that fast food is harmful, it can cause weight gain and increase the risk for CVD. As he was determinant to chase his dream to be a policeman, so he said goodbye to fast food.

Reference American Dietetic Association, 2000. Manual of Clinical Dietetics, 6th edition. American Dietetic Association, Chicago Illinois. Part 1: Nutrition Assessment, p3-67. American Dietetic Association, 2000. Manual of Clinical Dietetics, 6th edition. American Dietetic Association, Chicago Illinois. Chapter 23: Obesity, p365-386. Brody, T, 1999. Nutritional Biochemistry, 2nd edition. Academic Press, California. Part 4: Regulation of Energy Metabolism, p157-261. Guyton, AC and Hall, JE, 2006. Textbook of Medical Physiology, 11th edition. Elsevier Saunders, Philadelphia. Chapter 67: Metabolism of Carbohydrates, and Formation of Adenosine Triphosphate, p829-39. Guyton, AC and Hall, JE, 2006. Textbook of Medical Physiology, 11th edition. Elsevier Saunders, Philadelphia. Chapter 68: Lipid Metabolism, p840-48. Guyton, AC and Hall, JE, 2006. Textbook of Medical Physiology, 11th edition. Elsevier Saunders, Philadelphia. Chapter 69: Protein Metabolism, p852-57. Saladin, 2007. Anatomy & Physiology: The Unity of Form and Function, 4th edition. McGraw Hill Co, New York. Chapter 26: Nutrition and Metabolism, p986-94 and p996-1007. WHO, 1999. Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers.

SCENARIO IV
14 | P a g e

Fakultas Kedokteran Unram

Micronutrient Deficiency A 40 year-old woman came to Puskesmas with mass in her neck since 2 years ago. The mass seems to grow bigger but no complaint for pain nor swallowing. Her other complaints are getting tired easily, dry skin and constipation. Since she lives in mountain area far from city, the source of food she consumed are mainly come from nearby. She also did not know whether the salt used in her food contain iodine or not. At the moment, she is 3 months pregnant and worried the disease she has will affect the growth of her fetus. Doctor explains that she is having micronutrient deficiency, which is iodine deficiency. What micronutrients needed by our body to function well and what are the consequences of lacking or excess of them?

Reference Guyton, AC and Hall, JE, 2006. Textbook of Medical Physiology, 11th edition. Elsevier Saunders, Philadelphia. Dietary Balances; Regulation of Feeding; Obesity and Starvation; Vitamins and Minerals, p875-80. Bowman, BA & Russell, RM, 2001. Present Knowledge in Nutrition, 8th edition. ILSI Press, Washington DC. Part 3: Fat-Soluble Vitamins, p127-164. Bowman, BA & Russell, RM, 2001. Present Knowledge in Nutrition, 8th edition. ILSI Press, Washington DC. Part 4: Water-Soluble Vitamins, p127-72. Bowman, BA & Russell, RM, 2001. Present Knowledge in Nutrition, 8th edition. ILSI Press, Washington DC. Chapter 26: Calcium, p273-280. Bowman, BA & Russell, RM, 2001. Present Knowledge in Nutrition, 8th edition. ILSI Press, Washington DC. Chapter 29: Sodium, Chloride, and Potassium, p302-10. Bowman, BA & Russell, RM, 2001. Present Knowledge in Nutrition, 8th edition. ILSI Press, Washington DC. Chapter 30: Iron, p311-328. Bowman, BA & Russell, RM, 2001. Present Knowledge in Nutrition, 8th edition. ILSI Press, Washington DC. Chapter 32: Iodine and the Iodine Deficiency Disorders, p344-351. Brody, T, 1999. Nutritional Biochemistry, 2nd edition. Academic Press, California. Part 9: Vitamins, p491-692.

SCENARIO 5: The Wonders of the Human Body

15 | P a g e

Fakultas Kedokteran Unram

Lula is a student in the Medical Faculty. One day, she bought a snack from a nearby shop. Four hours later she suffered nausea and vomit which was followed by diarrhea. She feels that her symptoms were mild, therefore postponed to seek help from the doctor. Despite her symptoms she was still able to eat although not as much as usual. To her surprise, the next day she felt better. She then consulted her condition to one of her lecturer. The lecturer then assumed that she might suffered from mild food intoxication. To give better understanding on her condition, she was given an interesting article. An interesting paragraph in the article is stated as follow:

The human body is exposed to a wide array of xenobiotics during the course of our lifetime. Our bodies are capable in managing environmental product and also excessive intake of certain substance, thus minimize potential damage of various exposures. This is due to the role of certain organs that have developed complex enzymatic mechanisms. Nevertheless, it should be pointed out that the mechanism of detoxification and excretion itself exhibit significant individual variability, and are affected by many factors. As a consequence, the ability of detoxification and excretion of one individual may differ from the other.

Reference

Bowman, BA, and Russell, RM, 2001. Present Knowledge in Nutrition, 8th edition. ILSI, Washington DC. Chapter 50: Diabetes Mellitus, p.
American Dietetic Association, 2000. Manual of Clinical Dietetics, 6th edition. American Dietetic Association, Chicago Illinois. Chapter 20: Diabetes Mellitus, p.

16 | P a g e

Fakultas Kedokteran Unram

Annex 3
Name dr. Seto Priyambodo, MSc dr. Ida Ayu Eka Widiastuti, MFis Phone number 0817450525 081239553313 Block coordinator 1st week Coordinator and Medical skill laboratory instructur dr. Moulid Hidayat 081237352335 1st week Coordinator, Medical skill laboratory instructor, SOCA coordinator. dr. Hadian Rahman 08175737921 2nd week Coordinator and Medical skill laboratory instructur dr. Raehanul Bahraen Dr. Ardiana Ekawanti, M.Kes 08175752861 081353496220 2nd week Coordinator and Tutor 3rd weeks coordinator, Medical skill laboratory instructor and Written test coordinator Dr. Wahyu Sulistia Affarah 081803150805 3rd weeks coordinator and Medical skill laboratory instructur dr. Putu Aditya Wiguna 081907212887 4th week Coordinator, Tutor and CBT Coordinator dr. Monalisa, SpM Dr. Marie Yuni Andari, Sp.M dr.Dewi Suryani, M.ID dr. Yunita Sabrina, M.Sc. PhD. 081317303637 08123218548 082139223981 087864718100 4th week Coordinator and Tutor 5th week Coordinator and Tutor 5th week Coordinator and Tutor Journal reading coordinator and Tutor.

17 | P a g e