NUTRITION ASSESSMENT I. Importance A. Identify problems so corrective action can be taken to improve nutritional status. . !

etermine if a person is "ell nouris#ed enou$# to survive sur$ery or ot#er treatments. II. %omponents A. &istorical information . Ant#ropometric data %. ioc#emical 'laboratory( data !. )#ysical e*am III. &istorical information A. &ealt# #istory + may impact nutritional status ,. )revious or present alco#olism -. )revious or present disease conditions a. diabetes b. cancer c. renal disease d. t#yroid disorders .. )revious or present eatin$ disorders /. 0amily #istory of obesity 1. )revious sur$eries 2. Mental impairment 3. 4ei$#t c#an$es 5. !entition 6. E*ercise #abits . Socioeconomic #istory + personal7 environmental7 financial influences onfood intake ,. Eatin$ alone -. 8ack of money .. Inade9uate food preparation facilities /. )oor education 'e$7 readin$( 1. No transportation 2. 0amily problems t#at may result in lo" self esteem 'e$. E*cessive value of appearance in t#e family of a patient "it# eatin$ disorders( 3. !ru$ #istory a. antidepressants + increase or decrease appetite b. diuretics + may "aste potassium c. antacids 'bakin$ soda may contribute to sodium intake( d. vitamin:mineral supplements %. !iet #istory + provides a record of a person;s food intake so t#at nutrient intake can be estimated and provides information so dietitian can predict #o" "ell t#e client "ill accept diet c#an$es 'in $eneral7 t#e fe"est c#an$es from usual diet7 t#e better t#e compliance( ,. Information obtained a. types of foods consumed b. 9uantity of foods consumed 'food models #elp client estimate( c. #o" foods are prepared d. dinin$ out fre9uency e. bevera$e consumption 'includin$ alco#ol(

3.

f. supplement consumption -. Accuracy of data collected a. NON+<U!=MENTA8 + some people are very sensitive about eatin$ #abits and "ei$#t b. tec#ni9ue of askin$ 9uestions 'avoid leadin$ 9uestions( .. Tools a. -/+#our recall + record everyt#in$ eaten in t#e last -/ #ours ,. memory problem -. may not be typical day .. can do computeri>ed diet analysis b. Usual intake 'probably used most for diet #istories( ,. $ood for people "#o #ave re$ular eatin$ #abits -. sometimes used in combination "it# -/ #our recall .. can $ive overall impression of diet7 snackin$ patterns7 consumption of s"eets7 etc. c. 0ood fre9uency c#ecklist + #o" often t#e person eats food on a list 'several times a day7 daily7 "eekly7 mont#ly( ,. not e*tremely precise -. list of foods must be e*tensive .. can $ive $eneral impression of eatin$ #abits /. sometimes used in combination "it# -/ #our recall d. 0ood diary + prospective record of foods eaten over a period of time 'usually . days or 3 days(. Avera$e daily intake is calculated for eac# nutrient. ,. . days is pretty accurate if you #ave - "eekdays and , "eekend day -. %an $et info on time7 place7 "it# "#om7 and #un$er and emotional state .. <ust keepin$ a record may c#an$e a person;s food intake and t#erefore affect accuracy /. %an compare overall food #abits to $uidelines 'pyramid( for $eneral impression of dietary ade9uacy 1. If computeri>ed analysis is done7 can compare individual nutrients to R!As a. R!As are desi$ned for #ealt#y people b. computer analysis implies more accuracy t#an reality a. substitutions b. incomplete data on some nutrients c. nutrient levels in food composition tables are avera$es d. accuracy of portion si>es 2. %aveats a. Ade9uate intake doesn;t $uarantee ade9uate nutritional status 'may not absorb( b. Inade9uate intake doesn;t al"ays indicate deficiency ottom line + diet #istory $ives t#e dietitian a rou$# estimate of food intake so t#at problems or potential problems can be identified. Ultimate nutritional status can only be determined "#en diet #istory information is considered alon$ "it# ot#er components of nutritional assessment

II. Ant#ropometrics A. In $eneral ,. =ives information on body composition a. initial measurement provides baseline to monitor c#an$es in nutritional status b. monitors pro$ress of $ro"t# in pre$nant "omen and infants and $ro"in$ c#ildren c. detects undernutrition and obesity -. Measures are compared to standards from population studies a. problem + population data may not apply to a particular individual b. use a variety of ant#ropometric measures for most accurate ant#ropometric assessment . Ant#ropometric measures ,. &ei$#t and "ei$#t + most common a. &ei$#t ,. special e9uipment needed for kids under a$e . + lie kid do"n on special table "it# #ead at #ead board7 strai$#ten out le$s and take len$t# measurement at #eel -. adult + use stadiometer a. "it#out s#oes7 #eels to$et#er b. infle*ible ob?ect on top of #ead c. use a stool if you are s#orter t#an person d. can be estimated by -@ measurement from sternal notc# to fin$ertips e. can be estimated from knee #ei$#t b. 4ei$#t + beam balance7 electronic most accurate ,. infants + "ei$# in balance scale t#at allo"s kid to lie 'naked "it#out diapers( -. adults a. for repeated measures7 same scale7 same time of day7 after voidin$7 in same "ei$#t clot#in$7 "it#out s#oes7 mornin$ before breakfast is probably best .. Scales #ave upper limits + can add "ei$#ts to beam balance to increase limit /. Remember t#at a lot of people are sensitive about t#eir "ei$#t7 so don;t s#o" ?ud$ment c. Interpretation ,. infants to a$e -A use %!% $ro"t# c#arts a. $et percentile for #ei$#t and "ei$#t for a$e ,. 1At# percentile is avera$e -. #ei$#t and "ei$#t s#ould be "it#in percentile ran$es .. t#ere are c#arts for "ei$#t for #ei$#t MI7 and #ead circumference b. 8o" percentiles may not de due to undernutrition or poor #ealt#7 may be due to

$enetics 'are parents s#ortB7 is "ei$#t for #ei$#t OCB( c. Types of malnutrition indicated ,. acute 'recent poor intake( a. #ei$#t normal7 lo" "ei$#t b. "ei$#t is affected by malnutrition before #ei$#t 'lose body stores first7 t#en linear $ro"t# slo"s( -. acute on c#ronic + continuin$ lon$ term poor intake a. lo" "ei$#t and #ei$#t percentiles b. "ei$#t for #ei$#t lo" c. len$t# of time undernouris#ed #as affected linear $ro"t# as "ell as body stores .. past c#ronic a. lo" #ei$#t7 OC "ei$#t b. "ei$#t for #ei$#t may be OC c. past lon$ term undernutrition #as affected linear $ro"t#7but body stores #ave been repleted 'it takes lon$er for linear to catc# up NoteD #ave d. 8ook for trends in $ro"t# curve7sudden slo"s in $ro"t# are a concern e. Obese + try to #ave "ei$#t $ain slo" and let #ei$#t Ecatc# upE to "ei$#t -. Adults a. &ei$#t+"ei$#t tables 'Metropolitan7,65.( ,. based on mortality rates of insured population 'mostly "#ite( a. !ivided into frame si>e cate$ories ,. #t'cm(:"rist circ. 'cm( F r F small medium lar$e men G,A./ 6.2 + ,A./ H6.2 "omen G,,.A ,A., + ,,.A H,A.,

$ro"t# t#an body stores( if $ro"t# plates on bones closed7 catc# up $ro"t# "ill not occur

-. elbo" breadt# b. ot#er countries use ot#er standards '0AO:4&O(7 Indonesia #as o"n #+" tables

b. %alculation of ideal body "ei$#t 'I 4( ,. Traditional a. "omen ,. ,AA I for ,st 2A in -. add 1 I for eac# in7 over 2A .. lar$e frame7 add ,AJK small frame7subtract ,AJ /. e$ b. men ,. ,A2I for ,st 2A in. -. add 1 I for eac# in. over 2A .. add or subtract ,AJ dependin$ on frame si>e -. Ne"er 'closer to Ins. Tables( a. 4omenD ,,6L.I for every in. over 2A in. 'frame si>e ad?( b. Men ,.1L.I for every in. over 2. in. 'frame si>e ad?( c. d. e. f. $. %an add ,AJ for t#ose over 1A Subtract 1+,AJ for paraple$icK ,A+,1J for 9uadraple$ic Ran$e of "ei$#ts may be best )roblem + can be over"ei$#t "it#out bein$ over fat. 4#at to use in calculations ,. Ad?usted body "ei$#t 'for obese( a. useful for e9uations to calculate ener$y and protein needs b. .-1'%urrent 4 + I 4( L I 4

-. Actual body "ei$#t for t#ose "it#in normal "ei$#t ran$e .. !esirable body "ei$#t if under"ei$#t i. %linical interpretation JI 4 G-AA G,-A or ,.A ,,A + ,-A 5A + 6A 3A+36 H3A -. JU 4 Nutritional status morbidly obese obese over"ei$#t mildly undernouris#ed mod. undernouris#ed severely undernouris#ed

51+61 31+5/ H31

MI ' ody Mass Inde*( a. "ei$#t 'k$(:#t- 'm( b. -A + -1 + least risk of deat# c. MI G -1 is associated "it# obesity and $reater risk of

deat# d. =rades of obesity accordin$ to MI I -1 + -6.6 II .A + /A III /AL .. %ircumferences a. &ead + used in c#ildren7 estimates brain $ro"t# b. measure at lar$est part of #ead c. compare value to N%&S c#art /. 4aist+to+#ip ratio a. "aist + measure at umbilicus 'controversial( b. #ip + measure at lar$est circumference c. divide "aist by #ip d. interpretation ,. "omen G .57 apple 'android( -. men G ,.A7 apple 'android( e. android body fat distribution is associated "it# a $reater risk for some c#ronic diseases compared to $ynoid or perip#eral distribution 1. ody composition a. percent body fat ,. met#ods a. multiple site skinfold b. bioelectrical impedance c. dual ener$y *+ray absorptiometry d. body fat "and e. estimation by circumferences f. bod pod + air displacement -. interpretation a. appropriate levels not "ell defined M need to collect a lot more data over many years to correlate J body fat to lon$evity b. avera$e H .A y:o men G .A y:o men H .A y:o "omen G .A y:o "omen ,- + ,1J ,5 + -3J -- + -6J -1 + ./J

In $eneral7 over -1J in men and ..J in "omen is considered overfatK under .J in men and ,-J in "omen is underfat b. Somatic protein measures ,. #and $rip stren$t# + ne"7 not "idely used + stren$t# is correlated "it# malnutrition -. Mid+arm muscle circumference 'MAM%( + circumference of biceps muscle declines "it# malnutrition as protein reserves are depleted

III.

.. measurement a. Measure triceps skinfold b. Measure midarm circumference c. calculation + MAM% F Midarm circumference 'cm( + '..,/ triceps fatfold 'mm(( ioc#emical indices + tells "#at;s $oin$ on internally A. useful in assessin$ protein7 vitamin7 mineral status . Sensitivity + ability of a test to indicate abnormality "#en abnormality e*ists ,. some tests "ill not catc# a problem in early sta$es7 ot#er7 more sensitive tests "ill -. e$.7 #b:#ct are less sensitive t#an ferritin for determinin$ iron deficiency7 so #b:#ct does not dia$nose until anemia is advanced %. Specificity + ability of a test to indicate normal "#en no abnormality is present ,. Some tests of nutritional status can be abnormal for reasons ot#er t#an nutritional problems -. e$.7 Albumin could be lo" due to liver disease7 not deficient protein intake !. blood ,. serum 'blood minus cells and clot formin$ materials( -. plasma 'blood minus cells( .. tests a. SMA + simultaneous multiple analysis b. % % + complete blood count /. de#ydration concentrated blood and can falsely elevate values 1. #emodilution can falsely lo"er values 2. deficiency can be in pro$ress before lab values reflect because stores may be released into blood 3. metabolites "it# s#ort #alf+lives reflect recent nutritional status7 metabolites "it# lon$ #alf lives reflect lon$ term status a. albumin + #alf life -. days b. pre+albumin + #alf life . days 'detects 9uick c#an$es in nutritional status( !. Urine ,. specific $ravity + #ydration status -. nitro$en balance .. creatinine e*cretion E. %ommon tests related to nutritional state ,. )rotein nutrition a. albumin ,. lo" values indicate prolon$ed protein malnutrition 'lon$ #alf+ life and albumin can s#ift out of t#e cells into blood to slo" decline( -. slo" to respond to nutrition t#erapy so not $ood indicator of improvement of status .. disease states may affect albumin levels b. prealbumin M s#orter #alf life M tells recent c#an$es in protein c. transferrin 'protein t#at transports iron( status

,. s#ort #alf life7 small body pool -. not accurate indicator of protein status if iron status is poor d. retinol bindin$ protein 'carries vitamin A( and prealbumin are sensitive indicators e. total lymp#ocyte count 'T8%( + protein malnutrition depresses t#e immune system ,. run "it# % % -. %alculation + 4 % 'mm.( @ J lymp# f. Anti$en skin testin$ 'delayed #ypersensitivity '!&(+ anti$ens to "#ic# most people are immune are in?ected ?ust under t#e skin. After /5 #ours site is c#ecked for induration '#ard raised area(7 and is scored from A+-. If little or no induration + impaired immune status.'Ot#er factors can affect t#is test7 so it s#ould not be t#e sole bioc#emical test for malnutrition( $. Nitro$en balance + assesses rate of depletion or repletion ,. Nitro$en input F protein intake '$(:2.-1 -. Nitro$en output F amount of nitro$en in a -/ #our urine collection 'UUN( plus / 'skin7 fecal7 etc losses( .. nitro$en bal F input + output #. Urinary creatinine e*cretion ,. creatinine is a breakdo"n product of p#osp#ocreatine an ener$y source in skeletal muscle -. amount e*creted in urine is proportional to skeletal muscle mass .. as muscles atrop#y7 e*cretion decreases /. protein intake7 menstrual cycle can affect -. %#olesterol and lipoproteins .. &emo$lobin:#ematocrit + iron7 #ydration status IN. )#ysical e*am + p#ysical si$ns are last to appear in t#e pro$ression of malnutrition A. Steps of malnutrition ,. 8ack in diet '#istorical information( -. Stores decline 'ant#ropometric and bioc#em( .. ody functions abnormally 'bioc#emical( /. )#ysical si$ns appear NoteD Some p#ysical si$ns #ave lo" specificity7 e$7 dry7 scaly skin . Some p#ysical si$ns associated "it# malnutrition Si$n !ull7 t#in7 dry #air t#at is easy to pluck Scaly skin around nostrils7 c#eilosis S"ollen face )ossible nutrient deficiency )rotein riboflavin C"as#iorkor

)allor !ullness7 dryness of cornea itot;s spots 0issurin$ of eye corners Ma$enta ton$ue Atrop#y or #ypertrop#y of taste buds Mottled toot# enamel Spon$y7 bleedin$ receedin$ $ums T#yroid enlar$ed

Iron Nitamin A Riboflavin7 +2 Riboflavin 0olic acid7 niacin 0luoride e*cess Nitamin % Iodine

N. Estimation of nutrient needs A. ener$y maintenance needs+ &arris+ enedict e9uation ' EE( times activity and stress factors most commonly used ,. EE a. '"omen( F 221 L '6.2 @ "t 'k$(( L ',.3 @ #t'cm(( + '/.3 @ a$e 'years(( b. 'men( F 22 L ',..3 @ "t 'k$(( L '1 @ #t 'cm(( + '2.5 @ a$e 'years(( NoteD use ad?usted 4 if person is G,-1J I 4 -. multiply by eac# factor t#at applies a. Activity ,. very li$#t:sedentary ,.- +,.. -. 8i$#t 'no plnned activity7 mostly office"ork( ,.1+,.2 .. Moderate '"alkin$7 stairclimbin$ durin$ day( ,.2+,.3 /. &eavy 'planned vi$orous activities( ,.6+-., b. Stress ,. uncomplicated sur$ery ,., + ,.1 -. complicated sur$ery or fractures ,.- + ,./ .. Ma?or burn ,.1 + -.A c. 0ever ,.. for eac# de$ree % above nrml f. Anabolism ,. A.1 if pt e*perienced moderate "ei$#t loss -. ,., + ,.1 if pt e*perienced severe "ei$#t loss .. e*ample /. Alternative to &arris enedict times factorsD kcal @ k$ body "t

Sedentary Over"ei$#t Normal Under"ei$#t -A+-1 .A .A

Moderate .A -1 /A

Active .1 /A /1+1A

At#lete '6A min:d(D /1+1A kcal:k$ &ospitali>ed patients in stressD /A + /1 kcal:k$ Most ot#er #ospitali>ed patientsD .A+.1 kcal:k$ 1. E9uations provide a place to start + ad?ustment may be made for individual variation . )rotein ,. Nitro$en balance + Nitro$en in + Nitro$en out -. E9uations )erson )rotein needs per k$ body "t &ealt#y .5 + , 0ever7 fracture7 infection ,.1 + -.A )rotein depleted ,.1 + -.A E*tensive burns ,.1 + ..A Endurance at#lete ,.- M ,./ Stren$t# ,.2+,.3 NI. Special %onsiderations A. )re$nancy ,. blood volume e*pands7 #emodilution '&:& lo"( -. c#olesterol increases . Amputations + subtract accordin$ to J of body missin$ %. !eformed + may be impossible to measure accurately !. Elderly ,. naturally lose lean body mass and increase in proportion of fat as a$e7 t#en very old tend to lose fat stores -. )robably $ood to #ave some reserves .. &:& tend to be lo" + may be a normal process of a$in$ + less lean tissue7 don;t need as muc# #emo$lobin 'less tissue to o*y$enate( /. More prone to malnutrition a. lack of appetite b. presence of c#ronic diseases c. =I function declines d. many dru$s e. mental problems
Overall Macronutrient: Carbs General 60- 65% kcal

Protein

Endurance 65- 70% kcal or 7-10 g/kg General .8g/kg or 12- 15% kcal Endurance 1.2- 1.4 g/kg Strength 1.6- 1.7 Max of 30%

Fat