BIOCHEMICAL DATA, MEDICAL TESTS, AND PROCEDURES

Dr. Dinour NUFD 499

Specimen Types
Whole blood Serum Plasma Blood cells Erythrocytes Leukocytes Blood spots Other tissues Urine Feces

Biochemical Tests
Can potentially provide more objective and

Nutrition Interpretation of Routine Medical

Serum proteins Clinical chemistry panels Basic metabolic panel Comprehensive metabolic panel Complete blood count Disease-related tests Anemia Diabetes CVD HTN Osteoporosis

quantitative data on nutritional status than anthropometric, clinical, and dietary methods.

Can detect nutrient decits long before

anthropometric measures are altered or clinical signs and symptoms appear.

Some are useful indicators of recent nutrient intake

and can be used in conjunction with dietary methods.

Biochemical Assessment of
Methods for assessing somatic (skeletal muscle)

Acute-Phase Proteins
Class of proteins whose plasma concentrations increase

protein:

Lean body mass Creatinine-height index Midarm circumference Arm muscle area

(positive acute-phase proteins) or decrease (negative acute-phase proteins) in response to inflammation.

Positive acute-phase proteins: C-reactive protein Ferritin Negative acute-phase proteins: Albumin Transferrin Prealbumin

Methods for assessing visceral (organs, cells, serum)

protein:

Measuring serum proteins

Assessing Visceral Protein Status

Serum protein concentration can decrease in

C-Reactive Protein
Protein produced by the liver Measures general inflammation in the body Often used to check for infection after surgery or to keep

response to protein-energy malnutrition but is also a!ected by factors other than nutritional status.

track of infections/diseases that cause inflammation

Serum proteins with a shorter half-life (e.g.,

prealbumin) are more responsive to changes in nutritional status than those with a longer half-life (e.g., albumin).

Low risk: <1.0 mg/L Average risk: 1.0-3.0 mg/L High risk: >3.0 mg/L

Synthesis of some serum proteins (e.g., albumin,

transferrin, prealbumin) is decreased by the presence of acute-phase reactants released during the early

Albumin
Liver protein; transport molecule; maintains oncotic pressure Serum albumin often misinterpreted as a nutritional marker in

Comprehensive Metabolic Panel (CMP)

hospitalized patients
Neither sensitive to, nor specific for, acute protein malnutrition or

response to nutrition therapy

Albumin Factors That Decrease Factors That Increase

Normal: 3.5-5.0 g/dL Acute-phase response Depletion: Severe hepatic disease Mild: 3.0-3.4 g/dL Redistribution: intravascular Moderate: 2.4-2.9 g/dL volume overload, third Severe: <2.4 g/dL spacing, pregnancy, edema Acute catabolic status: Half-life: ~14-20 days nephrotic syndrome, burns,

Dehydration Intravenous albumin, blood transfusions (temporary rise) Anabolic steroids, possibly glucocorticoids

Glucose Sodium Potassium Carbon dioxide (bicarbonate) Chloride Blood urea nitrogen (BUN) Creatinine Calcium Albumin Total protein Alkaline phosphate (ALP) Alanine aminotransferase (ALT) Aspartate aminotransferase (AST) Bilirubin

CHEM-7

Italicized tests are also part of the basic metabolic panel (BMP)

Prealbumin
Carrier protein for thyroxin (thyroid hormone), and

BMP
Constituent Factors That Decrease Factors That Increase

combined with retinol-binding protein, transports vitamin A Often thought to be a more sensitive marker for protein and/or calorie deficiency; not affected by iron deficiency Should not be used as a sole criterion of malnutrition
Prealbumin Factors That Decrease Factors That Increase

Glucose, fasting Insulin overdose, bacterial 70-110 mg/dL sepsis, hypothyroidism, alcohol abuse, islet-cell carcinoma, extensive liver disease, Sodium Overhydration, edema, burns, starvation, pancreatitis 135-145 mEq/L vomiting, diarrhea, starvation, hyperglycemia, diuretics, SIADH Potassium 3.5-5.0 mEq/L Diarrhea, prolonged vomiting, excess diuretics (K-wasting), overhydration, alcohol abuse Diabetic acidosis, fever, acute infections, protracted vomiting, K deficiency, metabolic alkalosis, SIADH

Normal: 16-40 mg/dL Depletion: Mild: 10-15 mg/L Moderate: 5-9 mg/L Severe: <5 mg/L

Acute-phase response: stress, infection, surgery Severe hepatic disease (hepatitis, cirrhosis) Untreated hyperthyroidism Nephrotic syndrome

Moderate increase in acute or chronic renal failure Anabolic steroids, possibly glucocorticoids Hodgkins disease

Diabetes, Cushings syndrome, severe infections, thiamin deficiency, hyperthyroidism, pancreatitis, chronic hepatic Dehydration, severe malnutrition vomiting/ dysfunction, chronic diarrhea, fever, hyperventilation, open wounds, hyperglycemia, SIADH Renal failure, use of K-sparing diuretics, dehydration, acidosis, catabolism, tissue damage Dehydration, eclampsia, anemia, hyperventilation, diarrhea, renal insufficiency, metabolic acidosis, Cushings syndrome

Chloride 95-103 mEq/L

BMP
Constituent Factors That Decrease Factors That Increase

Complete Blood Count (CBC)

Red blood cells (RBC) Hemoglobin concentration (Hgb) Hematocrit (HCT) Mean corpuscular volume (MCV) Mean corpuscular hemoglobin (MCH) Mean corpuscular hemoglobin concentration (MCHC) White blood cells (WBC) Differential Neutrophils Lymphocytes Monocytes Eosinophils Basophils

Calcium Hypoalbuminemia, elevated 8.5-10.8 mg/dL phosphorus, diarrhea, hypoparathyroidism, malabsorption, alkalosis, renal or HCO3 Metabolic acidosis, renal failure, liver failure 21-28 mmol/L diabetic ketoacidosis, diarrhea BUN 8-23 mg/dL Creatinine 0.6-1.2 mg/dL Hepatic failure, malnutrition, malabsorption, inadequate protein intake, overhydration (excessive IV fluids), pregnancy, SIADH Pregnancy

Cancer, hyperthyroidism, chronic renal failure, hyperparathyroidism, adrenal insufficiency Metabolic alkalosis, emphysema, vomiting Renal failure (>50 severe impairment), shock, dehydration, infection, diabetes, excessive protein intake/catabolism, GI Acute and chronic renal disease, bleeding muscle damage, hyperthyroidism, starvation, high meat intake, muscle mass

CMP
Constituent Factors That Decrease Factors That Increase

CBC
Constituent Factors That Decrease Factors That Increase

Total protein 6.0-8.0 gm/dL ALP 20-150 U/L (adult) 100-420 U/L ALT (child) 4-36 U/L AST 8-33 U/L

Protein deficiency, severe hepatic disease, malabsorption, diarrhea, severe burns or infection, edema Hypophosphatemia, malnutrition, hypothyroidism, pernicious anemia, vit C deficiency, zinc deficiency, vit D excess

Dehydration

RBC Anemia, hemorrhage, iron F 3.5-5.5 million/mm3 deficiency, leukemia, lupus M 4.3-5.9 Hgb F 12-16 g/dL M 13.5-18.0 g/dL HCT F 37-47% M 42-52% MCV 87-103 m3/RBC Anemia, hyperthyoridism, cirrhosis, leukemia, lupus, HIV/AIDS Anemia, blood loss, hemolysis, leukemia, hyperthyroidism, cirrhosis, overhydration

Dehydration, severe diarrhea Severe burns, CHF, COPD, dehydration Dehydration, shock, chronic pulmonary disease, heavy smoking Alcohol abuse, macrocytic/megaloblastic pernicious anemias, vit B12 and/or folate

Hepatic disease, metastatic bone disease, hypercalcemia, pancreatitis, hepatitis, bone growth, rickets, osteomalacia Hepatitis, jaundice, cirrrhosis, hepatic cancer, MI, severe burns, trauma, shock, pancreatitis, obesity Uncontrolled DM, beriberi (thiamin Cell injury/death, MI, acute deficiency) cirrhosis, hepatitis, trauma, pancreatitis, renal disease, cancer, alcoholism, burns

CBC
Constituent MCH 26-34 pg/RBC MCHC 32-37 gm/dL WBC 5-10,000/L Factors That Decrease Microcytic anemia Iron deficiency, macrocytic anemia, chronic blood loss Some viral infections, chemotherapy, radiation, HIV/ AIDS, bone-marrow depression Factors That Increase Macrocytic anemia Spherocytosis (abnormal RBC membrane) Leukemia, bacterial infection, hemorrhage, trauma or tissue injury, cancer

Sickle Cell Anemia

Differentials Neutrophils 56% Eosinophils 2.7%

Anemias
More than 400 types of anemia, divided into three groups:
Anemia caused by blood loss GI conditions (ulcers, gastritis, cancer) NSAID use (aspirin, ibuprofen)
Menstruation, childbirth

Anemias
Anemias are defined based on cell size (MCV) and amount

of Hgb (MCH)

MCV less than lower limit of normal: microcytic anemia MCV within normal range: normocytic anemia MCV greater than upper limit of normal: macrocytic anemia MCH less than lower limit of normal: hypochromic anemia MCH within normal range: normochromic anemia MCH greater than upper limit of normal: hyperchromic

Anemia caused by decreased or faulty RBC production Sickle cell anemia Iron-deficiency anemia Vitamin deficiency
Bone marrow and stem cell problems Anemia of chronic disease (too few hormones for RBC production)

Anemia caused by destruction of RBCs (hemolytic anemia)

anemia

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Iron
The most common single nutrient deciency in the

United States and the most common cause of anemia.

Preschool children and women of childbearing age

are at greatest risk of iron deciency.

Inammation and infection are other common causes

of anemia, resulting in what is referred to as anemia of inammation.

Normal: F 60-160 mcg/dL, M 80-180 mcg/dL

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3 Stages of Iron Deficiency

First Stage: depleted iron stores Serum ferritin is decreased but other values remain within normal limits. Second Stage: early functional iron deciency

Ferritin
Ferritin is the primary intracellular iron-storage

protein, reects total body iron stores decrease.

As iron stores decrease, tissue and serum ferritin

without anemia

Serum transferrin is decreased, erythrocyte protoporphyrin

and soluble transferrin receptor are increased, hemoglobin likely to be at the low end of the normal range.

Serum ferritin concentration is the most sensitive

indicator of early iron deciency (rst stage of iron depletion). acute and chronic inammation.

Third Stage: iron deciency anemia Hemoglobin, serum ferritin, transferrin saturation, and mean corpuscular volume (MCV) are decreased and erythrocyte protoporphyrin and soluble transferrin receptor are increased.

It is an acute-phase protein that is increased during

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Total Iron Binding Capacity (TIBC)

Indirect measurement of serum transferrin Reflects the amount of transferrin receptors available for

Hemoglobin
An iron-containing molecule found in RBCs capable

of carrying oxygen and carbon dioxide.

iron binding
It generally does not become abnormally low until Normal: 250-460 mcg/dL

the last stage of iron depletion and is not a suitable indicator of early iron deciency.

It fails to distinguish between iron deciency anemia

and anemia of inammation.

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Transferrin
Binds and transports iron; inversely correlated with bodys

Folate
Folate deciency can inhibit DNA synthesis and

iron stores
Levels reduced in severe protein-calorie malnutrition, but

may be variable in mild-moderate degrees of malnutrition

Transferrin Factors That Decrease Factors That Increase

impair cell division, especially during periods of rapid cell division and growth such as pregnancy and infancy.

Marginal folate intake during pregnancy increases the

risk of an infant being born with a neural tube defect. of folic acid to enriched cereal products.

Beginning in 1998 the U.S. FDA required the addition

Normal: 200-400 mg/ dL Depletion: Mild: 150-200 mg/dL Moderate: 100-149 mg/dL Severe: <100 mg/dL Acute-phase response Iron deficiency, chronic Chronic or end-stage liver blood loss disease Pregnancy (markedly Uremia increases in 3rd Protein-losing states: some trimester) nephrotic syndromes, burns Intravascular volume Intravascular volume overload, depletion, dehydration

Since then, serum folate concentrations in the U.S.

have more than doubled, RBC folate concentraton has

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Assessing Folate Status

Serum Folate Concentration Reects recent folate intake, can uctuate daily depending on intake, does not necessarily represent tissue stores. Normal: 5-25 ng/mL RBC Folate Concentration Considered the best clinical index of folate stores in the bodys tissues, reects folate status at the time an RBC was synthesized, and is less subject to uctuations in dietary intake. Normal: 150-450 ng/mL

Assessing B-12 Status

Direct measures of serum or plasma B-12 Normal: 160-950 pg/mL Measuring metabolites or functional biomarkers that

accumulate when B-12 status is inadequate

Urinary or serum methylmalonic acid (MMA) which are increased

with inadequate B-12 status.

Normal: 73-271 nmol/L

Plasma total homocysteine (tHcy) which increases when B-12 and

folate status are inadequate.

Normal: 4-14 mol/L

MMA and tHcy are also increased by impaired renal function, which

is common in the elderly.

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Vitamin B-12
The diets of most Americans supply more than

Iron-Deficiency Megaloblastic Anemia Anemia (Folate) Hgb HCT MCV MCH Decreased Decreased Decreased Decreased Decreased Decreased Increased Increased Decreased Normal Decreased Decreased Increased Increased Normal Increased Decreased Decreased Increased Normal Decreased

Pernicious Anemia (B12) Decreased Decreased Increased Increased Normal Increased or normal Decreased or normal Decreased or normal Increased or normal Decreased Normal or increased

Anemia of Chronic Disease Decreased Decreased Normal Normal Normal Decreased Decreased or low-normal Decreased Increased or normal Normal Normal or decreased

adequate amounts of vitamin B-12.

Average B-12 intake is well above the RDA for all

MCHC Serum Fe TIBC

sex-age groups, including pregnant and lactating females.

Vitamin B-12 deciency does occur, but usually

because of inadequate absorption, rarely because of a dietary deciency.

Absorption of B-12 is largely dependent on the presence of

Transferrin Serum Ferritin Serum B12 Serum Folate

intrinsic factor (IF) which is produced by the parietal cells of the gastric glands.

Diabetes Mellitus
A group of metabolic diseases characterized by

A Diagnosis of Diabetes is Made if Any

Casual Plasma Glucose ! 200 mg/dL with classic

hyperglycemia resulting from defects in insulin secretion, insulin action, or both.

diabetes symptoms (polyuria, polydipsia, unexplained weight loss) OR

Also present are abnormalities in the metabolism of: Carbohydrate Proteins & amino acids Lipids Conditions of impaired glucose metabolism Type 1 diabetes mellitus Type 2 diabetes mellitus Gestational diabetes mellitus (GDM) Impaired fasting glucose (IFG)
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Fasting Plasma Glucose ! 126 mg/dL OR OGTT value of ! 200 mg/dL in the two-hour sample

OR

Hgb A1c " 6.5%

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Pre-Diabetes
A term used to describe patients with either impaired

fasting glucose or impaired glucose tolerance.

Patients with pre-diabetes are at increased risk of

developing diabetes in the future.

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Glycated Hemoglobin
Referred to as A1C or hemoglobin A1C. Hemoglobin which has a glucose molecule

Gestational Diabetes Mellitus

A diagnosis of GDM is made if any one of the

following plasma glucose values are exceeded:

Fasting: " 92 mg.dL 1 hour: " 180 mg/dL 2 hour: " 153 mg/dL

irreversibly attached to it.

It is a marker of long-term glycemic control,

reecting average blood glucose levels during the past 8 to 12 weeks. been, the greater the percentage of hemoglobin which is glycated.
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The greater the average blood glucose level has

Gestational Diabetes Mellitus

At the first prenatal visit, all women should be screened for

Lipid/Lipoprotein Screening in Adults

Lipid/lipoprotein panel for all adults beginning at age

risk factors for diabetes and tested, if indicated.

If, at this time, a woman is found to have diabetes, she is

20 years (fasting TC, LDL-C, HDL-C, TG) and every 5 years.

diagnosed as having overt diabetes, not gestational diabetes.

If not found to have overt diabetes, she should be

If results are abnormal, repeat at appropriate

intervals to evaluate response to Therapeutic Lifestyle Change and drug therapy.

screened for GDM at 24-28 weeks with a 2-hr, 75 g OGTT.

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Total and HDL-Cholesterol Classifications

Total Cholesterol < 200 Desirable 200-239 Borderline High > 240 High HDL- Cholesterol < 40 Low (undesirable) ! 60 High (desirable)

LDL-C Classifications for Adults

< 100# 100129# 130159# 160189# ! 190# Optimal Near optimal/above optimal Borderline high High Very high

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Triglyceride Classifications for Adults

< 150# 150199# 200499# ! 500# Normal Borderline high High Very high

Lipid/Lipoprotein Screening in Children

Universal screening between ages 9 and 11 years and

again between ages 17 and 21 years.

Targeted screening at other ages after 2 years of age if

any of the following are present:

Family history of elevated total cholesterol. Family history of premature CVD. The child or adolescent has one or more major CVD risk factor.

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Classifying Total and LDL-Cholesterol in

Total Cholesterol < 170# Acceptable 170-199# Borderline > 200# High LDL- Cholesterol < 110# Acceptable 110-129# Borderline " 130# High
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Classifying Triglycerides in Children

Birth to 9 Years of Age < 75# Acceptable 75-99# Borderline " 100# High 10 to 19 Years of Age < 90# Acceptable 90-129# Borderline " 130# High
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Classifying HDL-C and Non-HDL-C in

HDL-Cholesterol > 45# Acceptable 40-45# Borderline < 40# Low Non-HDL- Cholesterol < 120# Acceptable 120-144# Borderline " 145# High
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Blood Pressure Classifications for

BP Classication Normal SBP mmHg < 120 DBP mm Hg < 80 80-89 90-99 ! 100

Prehypertension 120-139 Stage 1 hypertension Stage 2 hypertension 140-159 ! 160

an d or or or

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Classifying Blood Pressure in Children

Hypertension is an average SBP or DBP "

Normal Bone Biopsy Specimen

95th percentile of BP for sex, age, and stature on three or more occasions.

Prehypertension is an average SBP or DBP

" 90th percentile but < 95th percentile for sex, age, and stature on three or more occasions. < 95th percentile should be considered

Adolescents with BP " 120/80 mm Hg but

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Osteoporosis and Osteopenia

Conditions characterized by low bone mineral density

Bone Biopsy of Osteoperosis

(BMD), structural deterioration of the bones, bone fragility, and increased susceptibility of fracture.

Osteopenia is a term used to describe a bone mineral

density (BMD) that is abnormally low, but not low enough to be diagnostic for osteoporosis.

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Assessing Vitamin D Status

Vitamin D status is best assessed by measuring the

Calcium Status
Attempts to identify a calcium status indicator in the

serum concentration of 25-hydroxyvitamin D [25(OH)D] which reects total vitamin D exposure from food, supplements, and synthesis.

blood have been unsuccessful and currently there is no appropriate biochemical indicator for assessing calcium status.

There is disagreement among researchers on what

serum concentrations of 25(OH)D represent an optimal vitamin D exposure.

The most feasible approach for assessing calcium

status is measurement of bone mineral content using dual-energy X-ray absorptiometry (DXA).

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DXA Unit

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Example DXA Scan of the Hip

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Osteoporosis and Osteopenia

Diagnosed by comparing a patients BMD as

Activities
Case study (to be handed out in class) Develop a lab profile for your partner based on the

measured using DXA with the mean normal BMD of healthy young adults of the same sex using what is called a T-score.
Osteoporosis is dened as a BMD " 2.5 SD below the average

BMD value for healthy, young adults of the same sex. A Tscore -2.5 or less

assessment data you have obtained so far. Consider hydration status and chronic conditions, and include at least the BMP and CBC.

Osteopenia is dened as a BMD 1.0 to 2.5 SD below the

average BMD value for healthy, young adults of the same sex. A T-score between -1.0 and -2.5

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For Next Class

We will be determining nutritional needs via the BodyGem

metabolism measurement device (measures resting metabolic rate). To get an accurate reading, please:
Do not eat for at least 4 hours prior class Do not exercise for at least 4 hours (aerobic or strength training)

prior to class
Do not consume caffeine or nutritional supplements or medications

containing ephedra, Ma Huang, or pseudoephedrine for 4 hours prior to class

Do not smoke or use nicotine for 1 hour prior to class