ASSIEGNMENT

ON

Assessment of Nutritional Status

COURSE NAME: METHODS FOR NUTRITIONAL STATUS

SUBMITTED BY SUBMITTED TO

MEHEDI HASAN BAPPY Ms. Fouzia Akter

ID: 163-34-566 Senior Lecturer
Introduction

Nutritional assessment is the systematic process of collecting and interpreting information in

order to make decisions about the nature and cause of nutrition related health issues that affect an
individual (British Dietetic Association (BDA), 2012).

This differs from nutritional screening (link to Screening and MUST page) which is a brief risk
assessment which can be carried out by any healthcare professional and which may lead to a
nutritional assessment by a dietetician.

Following a structured assessment path enables health professionals to carry out a quality
nutritional assessment in order to identify those who need nutritional intervention, and to
improve clinical decision making using a person centred approach. The process promotes
consistent quality of practice; is user friendly; and allows effective monitoring of patients. A
structured assessment pathway does not remove autonomy; it encourages professional judgement
and informed decision making at every stage. The process provides a rationale for the nutritional
intervention, and allows for revision of the plan as individual circumstances change over time.

Assessment
A: Anthropometry
Anthropometry allows for an assessment of the different component parts of the human body.
Body composition refers to the anatomical makeup of the body in terms of bone, muscle, water
and fat. A single measure will not provide a comprehensive overview of the patients condition
and so a number of measurements are required to form a more reasoned assessment. In
malnutrition, changes in body composition lead to Introduction to Malnutrition.

Anthropometric measurements that can be used to assess body composition.

Measurement Equation/ method Interpretation of results

Weight and % weight change % weight change = (current A patient is indicated for
weight - previous weight/ nutrition support if they have:
current weight) x 100
BMI <18.5kg/m2

Unintentional weight
loss of >10% in the
previous 3-6 months

BMI <20kg/m2 and

unintentional weight
 Measurement
Body mass index (BMI)
Mid upper arm circumference
(MUAC)
Skin fold thickness
Equation/ method Interpretation of results
loss >5% in the previous
3-6 months.
(NICE, 2006)
If BMI <18.5kg/m2
patient is underweight
If BMI 18.5-25kg/m2
patient is in normal BMI
BMI (kg/m2) = weight (kg) /
range
height 2 (m2)
If BMI >25kg/m2 patient
is overweight
(WHO, 2016)
If MUAC is >23.5cm
Involves measuring the
the patient is likely to
circumference of the mid-point
have a healthy BMI and
on upper arm using a tape
is at low risk of
measure. This is a surrogate
malnutrition.
measure of both fat mass and fat
free mass. It is a useful measure
when a person cannot be If MUAC is <23.5cm
weighed or if their weight is not the patient is likely to
likely to be a true reflection of have a BMI <20kg/m2
the persons actual weight, e.g. and may be at risk of
if the patient has oedema or malnutrition.
ascites.
(BAPEN, 2011)
Measurement requires a trained Centile tables can be used to
person using skin fold callipers interpret skin fold thickness
which have been calibrated. measurements.
Skin fold measurements can be
taken at 4 different sites:
suprailliac, subscapular, biceps,
triceps (TSF; most commonly
used). Measurement should be
repeated 3 times and the mean
result recorded. This is a
 Measurement Equation/ method Interpretation of results
surrogate measure of total fat
mass. Longitudinal
measurements can be used to
identify any changes in fat
mass.
MAMC is a surrogate measure
of fat free mass and is
calculated using MUAC and Centile tables allow assessment
Mid arm muscle circumference
TSF. of changes in total body muscle
(MAMC)
mass over time.
MAMC (cm) = MUAC (cm)
3.14 x TSF (cm)

Other visual signs may indicate recent weight loss such as loose jewellery, baggy clothes, extra
notch in belt, ill-fitting dentures, loose or thin looking skin, and prominent bony features.

B. Biochemistry
The blood tests conducted within a nutrition assessment are interpreted in conjunction with a
clinical examination; previous medical history; and current medications. Biochemistry tests
measure levels of chemical substances present in the blood. Functional tests measure the function
of vital organs such as the kidneys or liver.

Normal range (note that

Measurement Rationale different laboratories may use
different reference ranges)
Assess for iron status or Women = 12.0 to 15.5 g/dl
Haemoglobin (Hb)
indicate anaemia. Men = 13.5 to 17.5 g/dl
A low level may indicate
inflammation or infection is
Albumin (Alb) present, therefore should not be 35 - 50 g/L (3.5 - 5.0 g/dL)
used to determine nutritional
status.
This is an inflammatory marker
C-Reactive Protein (CRP) which is raised when infection Ideally <10 mg/L
or inflammation is present.
Immune system marker; is 4-11 x109/L (4000-11,000 per
White cell count (WCC)
raised if infection is present. cubic millimetre of blood)
Indicates an average blood
Glycated Haemoglobin Ideally <48 mmol/mol or <6.5%
sugar level over a period of
(HbA1c) (Diabetes UK)
months.
This is an indication of
hydration status and kidney
Sodium (Na) 135-145 mmol/L
function. A raised sodium level
may indicate dehydration.
 Normal range (note that
Measurement Rationale different laboratories may use
different reference ranges)
Used to assess kidney function.
High urea and other markers
Urea (Ur) 2.5-7.1 mmol/L
levels in combination may
indicate dehydration.
Used as a baseline when
assessing risk of refeeding Adjusted Ca 2.0-2.6 mmol/l
Calcium and Phosphate
syndrome Calcium is adjusted Phosphate 0.7-1.4 mmol/l
for albumin level
Likely to be low if there are
Magnesium 0.7-1.0 mmol/l
large GI losses
Include vitamins and trace
Micronutrients elements. These are affected by
the acute phase response if
inflammation or infection is
present and so best measured
when CRP is low

VITAMIN A STATUS
Vitamin A status can be grouped into five categories: deficient, marginal. adequate.
excessive, and toxic. In the deficient and toxic states, clinical signs are evident, while
biochemical or static tests of vitamin A status must be relied in the marginal, adequate,
and excessive states. Biochemical assessment of vitamin A status generally involves static
measurements of vitamin levels in serum, breast milk, and liver tissue and functional
tests, such as dose-response tests, examination of epithelial cells of the conjunctiva, and
assessment of dark adaptation.

VITAMIN C STATUS
vitamin C is a generic term compounds exhibiting the biological activity of ascorbic acid,
the reduced form of vitamin C. The oxidized form of vitamin C is known as
dehydroascorbic acid The sum of ascorbic and dehydroascorbic acid constitutes all the
naturally occurring biologically active vitamin C. Vitamin C is necessary for the
formation of collagen; the maintenance of capillaries, bone , and teeth ; the promotion of
iron absorption; and the protection of vitamins and minerals from oxidation.

VITAMIN B6 STATUS
The vitamin group is composed of three naturally occurring compounds related
chemically; metabolically; and functionally: pyridoxine (PN). pyridoxal (PU). and
pyridoxamine (PM). Within the liver, erythrocytes and other tissues of the body, these
 forms are phosphorylated into pyridoxal 5 phosphate (PLP) and pyridoxamine
phosphate (PMP). PLP and PMP primarily serve as coenzymes in a large variety of
reactions.
Especially important among these are the transamination reactions in protein metabolism.
PLP also is involved in other metabolic transformations of amino acids and in the
metabolism of carbohydrates ,lipids, and nucleic acids.
Because of its role in protein metabolism, the requirement for vitamin B6 is directly
proportional to protein intake.

FOLATE STATUS
Folate, or folacin, is a group of compounds with properties and chemical structures
similar to folic acid, or pteroylglutamic acid. Folate functions as a coenzyme transporting
single carbon groups from one compound to another in amino acid metabolism and
nucleic acid synthesis. One of the most significant of folates functions appears to be
purine and pyrimidine synthesis. Folate deficiency can lead to inhibition of DNA
synthesis, impaired cell division, and alterations in protein synthesis. These effects are
especially seen in rapidly dividing cells (such as crythrocytes and leukocytes).

VITAMIN B12 STATUS

Vitamin B12, or cobalamin. include a group of cobalt- containing molecules that can be
converted to methylcobalamin or 5 -deoxyadenosylcobalamin, the two coenzyme forms
of vitamin B 12 that are active in human metabolism. Vitamin B12, is synthesized by
bacteria. fungi. and algae, but not by yeast, plants. and animals. Vitamin B12 synthesized
by bacteria accumulates in the tissues of animals that are then consumed by humans.
Thus, animal products serve as the primary dietary source of vitamin B12. Although
plants are essentially devoid of vitamin B12 (unless they are contaminated by
microorganisms or soil containing vitamin B 12) foods such as breakfast cereals, soy
beverages, and plant-based meat substitutes are sometimes fortified with vitamin B12.

BLOOD CHEMISTRY TESTS

Blood chemistry tests include a variety of assays performed on plasma or serum that are
useful in the diagnosis, and management of disease. They include electrolytes, enzymes,
metabolites. and other miscellaneous substances. When run at one time, blood chemistry
tests often are known by such names as the chemistry profile, chemistry panel, chem
profile, and chem panel. To perform these tests, clinical laboratories use an automated
analyzer capable of performing several thousand blood tests per hour.
The patients plasma or serum sample is placed into the analyzer, which performs the
desired tests and provides a printout of the patients results, including reference ranges
and flagged abnormal results. A related series of tests, often known as the coronary risk
profile, measures levels of triglyceride, total cholesterol, and HDL-C (cholesterol carried
by high-density lipoproteins) and calculates LDL-C (cholesterol carried by low-density
lipoproteins) and, in some instances, the total cholesterol! HDL-C ratio.
 Following is a brief overview of the major blood chemistry tests. Normal adult serum
levels (known as reference ranges) are given. These reference ranges vary, depending on
the individual biochemical and analytic method used. It is generally best, however, to use
reference ranges suggested by the laboratory performing the analyses.

C. Clinical
A persons disease state may increase the risk of malnutrition due to increased energy
requirements; reduced energy intake; or increased nutritional losses. Examples of
diseases/conditions where this may occur include:

Cancer

Chronic Obstructive Pulmonary Disease

Heart failure

Gastrointestinal disorders such as Crohns disease, liver disease, coeliac disease

Neurological conditions such as stroke, Motor Neurone Disease, Parkinsons Disease,

multiple sclerosis, dementia

Burns, surgery or trauma

Mental health conditions (such as depression)

Symptoms that may impact on a persons nutritional status either through reducing nutritional
intake or increasing nutritional losses include:

altered bowel movements e.g. diarrhoea, constipation

upper gastrointestinal upset e.g. reflux, bloating, nausea, and vomiting.

early satiety

dysphagia

lethargy
D. Dietary

DEFINITIONS OF SELECTED INDICATORS

Dietary Diversity: The number of foods or food groups (in this study) consumed in the
reference period.
Elasticity: the percentage change in the dependent variable given a one percent change in an
independent variable.
Dietary Variety: a term often used in the literature and it is considered here as synonymous to
dietary diversity.
Food Groups: A total of 12 food groups adopted from the FAO classifications as outlined: 1)
Cereals, 2) Meat and meat products, 3) Roots and tubers, 4) Vegetables, 5) Fruits, 6) Beans and
other pulses, 7) Dairy products, 8) Fats and oil, 9) Sugars and honey, 10) Fish and sea foods, 11)
Eggs, 12) beverages, spices & other products was used in this specific study.
Food security: When all people at all times have both the physical and economic access to
sufficient food to meet their dietary needs in order to lead productive and healthy life (USAID
definition).
Food access: a measure of the households ability to acquire food over a reference period
Food acquisition: The amount of food consumed by all members of household over a defined
period of time (for instance, last 24 hours in this study).
Household caloric availability: the amount of calories accessed by the household; its derived
from data on food acquisition.
Household consumption: the nutrient value of food and non-food goods consumed by the
household over a reference period (24 hours in this study).
Household per capita caloric availability: Household caloric availability divided by the
number of consumers

Household per capita consumption: Household consumption divided by the number of

household members

Energy requirements

1. Estimate Basal Metabolic Rate (BMR) using Henry Equations (2005) based on age,
gender and weight (Henry, 2005) or estimate requirements for stable patients using 25-
35kcal/kg (NICE 2006).

2. Add factor when patient is metabolically stressed

3. Add factor for activity and diet induced thermogenesis

4. If aiming for weight gain, add 400-600 kcal/day. Only add this for patients who are
metabolically stable (i.e. not acutely unwell).

5. There are a number of alternative methods to calculate energy requirements in patients

who are obese, with care required not to over-estimate requirements.

(Weekes and Soulsby, 2011)

Fluid requirements:

Aged >60 years = 30ml/kg body weight

Aged <60 years = 35ml/kg body weight (Todorovic and Micklewright, 2011)

Dietary assessment:

An estimation of the total daily calorie intake, as well as overall quality of diet should be
assessed. Asking the patient (or their family/carer if patient unable) about their daily dietary
intake will help understand patterns of eating, portion sizes, cooking methods and types of food
and drink taken. Consider asking the following questions to help form a better understanding of
the patients overall diet:

What is the patients typical food and fluid intake? This can be recorded using food
record charts; 24-hour recall; 3-day food diary; or typical day diet history.

Is the patient eating 3 meals a day?

Do they have pudding after at least one meal per day?

Are they eating snacks in between meals?

Are they eating smaller meals than they used to when they were feeling well?

Are they having regular drinks, at least 6-8 glasses of fluid/ day?

Are they having nutritious drinks such as milky tea/coffee, fruit juice, milky drinks?

Are they having carbohydrate foods (bread, potatoes, pasta, rice, breakfast cereals etc)
and protein foods (meat, cheese, beans, egg, fish, milk, yoghurt, cream) at each meal
time? Portion sizes should be at least the size of the patients fist and amount to 1/3 each
on the plate (carbohydrate, protein, vegetables).

Are they eating at least one portion of fruit or vegetable each day?

If food is being blended, are they adding nutritious liquids such as milk, cream or gravy
to aid blending, rather than water?

Are they able to cook for themselves?

Do they have access to essentials such as bread, milk and cheese on a daily basis?

Do they have a hot/cooked meal each day?

Are they taking any nutritional supplements? Do they take them as recommended? Do
they like them?
E Environment

Ability to shop, cook, assistance with eating and drinking, mobility, budget restraints, limited storage facilities, m

Assessment of risk of re-feeding syndrome:

Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that
may occur in malnourished patients on refeeding following a period of starvation (NICE, 2006).
This is particularly common in patients receiving artificial refeeding, but is possible with oral
refeeding (particularly if oral nutritional supplements are prescribed). The patient should be
considered at risk of refeeding syndrome if they meet the following criteria (NICE 2006).

If the patient has one or more of the following:

Body mass index <16 kg/m2

Unintentional weight loss >15% in the past three to six months

Little or no nutritional intake for >10 days

Low levels of potassium, phosphate, or magnesium before feeding

Or the patient has two or more of the following:

Body mass index <18.5 kg/m2

Unintentional weight loss >10% in the past three to six months

Little or no nutritional intake for >5 days

History of alcohol misuse or drugs, including insulin, chemotherapy, antacids, or

diuretics

If the patient is considered to be at high risk of refeeding syndrome, the following steps are
advised by NICE (2006):

Start nutrition support at a maximum of 10 kcal/kg/day, increasing levels slowly to meet

or exceed full needs by 47 days

Restore circulatory volume and monitoring fluid balance and overall clinical status
closely
 Provide immediately before and during the first 10 days of feeding: oral thiamine 200
300 mg daily, vitamin B co strong 1 or 2 tablets, three times a day (or full dose daily
intravenous vitamin B preparation, if necessary) and a balanced multivitamin/ trace
element supplement once daily

Provide oral, enteral or intravenous supplements of potassium (likely requirement 24

mmol/kg/day), phosphate (likely requirement 0.30.6 mmol/kg/day) and magnesium
(likely requirement 0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral) unless pre-
feeding plasma levels are high. Pre-feeding correction of low plasma levels is
unnecessary