BIOCHEMICAL ASSESSMENT

 Estimation of tissue desaturation,

enzyme activity or blood
composition. Tests are confined of
two easily obtainable fluids namely
blood and urine and results are
generally compared to standards
IDEAL BIOCHEMICAL TEST
1. Specific
2. Simple
3. Inexpensive
4. Reveal tissue depletion at an early
stage
OBJECTIVES OF LABORATORY 5. Require less sophisticated
ASSESSMENT equipment and skill
1. To detect marginal nutritional 2 TYPES OF TEST EMPLOYED IN LAB
deficiency in individuals, particularly SURVEYS
when dietary histories are
questionable or unavailable; this is 1. Static biochemical tests- measure of a
especially important before overt nutrient or its metabolite in blood, urine, or
clinical signs of diseases appear, thus body tissue (an actual measure of the
permitting the initiation of nutrient)
appropriate remedial steps. EX: Iron or Vitamin A
2. To supplement or enhance other LIMITATIONS: may fail to reflect the
studies such as dietary or community overall nutrient status (serum may not reflect
assessment among specific level of nutrient in tissue)
population groups in order to pinpoint
a. Involves measurement of levels of a
nutritional problems that these
nutrient or a metabolite in a preselected
modalities may have suggested or
biopsy material that reflects either the
failed to reveal.
total body content of the nutrient or the
FACTORS AFFECTING ACCURACY size of the tissue store most sensitive to
OF RESULTS depletions are measured.
1. Method of sample collection b. Categories:
2. Method of transport and storage 1. Measurement of a nutrient in biological
fluids or tissues (biological fluids or tissues
of samples used are blood, urine, hair, saliva, semen,
3. Technique employed amniotic fluid, fingernails, skin and buccal
mucosa)
2. Measurement of the urinary excretion rate ASSESSMENT OF PERFORMANCE
of the nutrient OF LABORATORY TESTS
a. Reflects recent dietary intake or acute 1. Accuracy
status
2. Precision
b. Urine cannot be used to assess vitamins A,
D, E, and K as metabolites are not excreted 3. Within assay variability
in proportion to the amount of these vitamins 4. Between assay variability
consumed, absorbed, and metabolized
BIOCHEMICAL MEASUREMENTS OF
c. Can be used for assessment of some SELECTED NUTRIENTS
minerals, water-soluble B-complex
vitamins, vitamin C, and protein 1. Protein status- Laboratory indices of
protein status measure somatic protein
2. Functional tests – reflects the failure of status, visceral protein status, metabolic
function or physiologic process of the body changes, muscle function and immune
as a result of nutritional deficiency function.
(somewhat indirect measure)
Example: immune response will be A. Urinary creatinine excretion
1. Urinary creatinine is used to assess the
compromised by protein deficiency, visual
adaption to dark will compromised by degree of depletion of muscle mass in
marasmic patients, and degree of
vitamin A deficiency.
repletion is often long term intervention,
LIMITATIONS: may be nonspecific; provided that 72-hour urine collections
indicates a general nutritional status, but may are made.
not allow it of specific nutrients. - Frequently expressed as creatinine
height index (CHI)
a. Defined as “diagnostic tests to determine
the sufficiency of host nutriture to permit
cells, tissues, organs, anatomical systems, or
the host to perform optimally the intended,
nutrient- dependent biological function”
b. Indicates severity of deficiency; measures
the effect of lack thereof on the enzymes by
which the body makes use of its nutrient
intake.
c. Categories:
1. Enzymatic tests which measures the
activity of an enzyme which requires the
vitamin as a coenzyme added in vitro
2. Metabolic test which measures the rise in A. Urinary creatinine excretion
concentration of metabolite in blood or urine Factors affecting daily creatinine
after administering a load of an appropriate exretion
precursor
a. Diurnal and day to day variations
 b. Strenuous exercise
c. Emotional stress
d. Dietary intakes of creatine and
creatinine
e. Menstruation
f. Age
g. Infection, fever and trauma
h. Chronic renal failure
B. 3- methylhistidine excretion
 3- methylhistidine is an amino acid
present almost exclusively in the actin
of all skeletal muscle fiber and the
myosin of white fiber, a marker of
muscle protein that is not widely used
C. Serum protein
1. An index of viscelar protein status;
easily measured but a rather insensitive
index of protein status
2. Factors affecting serum protein
concentrations
a. Inadequate protein intake
b. Altered metabolism
c. Specific deficiency of plasma protein
d. Reduced protein synthesis
e. Pregnancy
f. Capillary permeability
g. Drugs
h. Strenuous exercise

H. SERUM SOMATOMEDIN C
Somatomedins are growth-hormone
dependent serum growth factors produced by
the liver. They circulate bound to carrier
proteins and have a half-life for several hours.
More sensitive to acute changes in protein
status than the other serum proteins.
J. URINARY 3-HYDROXIPROLINE
EXCRETION
1. Urinary 3-hydroxyproline is an excretory
product derived from the soluble and
insoluble collagens of both soft and calcified
tissues.
2. Hydroxyproline: creatinine ratio
(corrects for differences in adult body size)
Hydroxyproline (mg) per 24 hr Creatinine
(mg) per 24 hr
3. Hydroxyproline index
Hydroxyproline index= mg hydroxyproline
per mL urine x kg body weight / mg
creatinine per mL urine
M. Functional test
 Functional test of protein status include
muscle function measure changes in muscle
contractility, relaxation rate, endurance, and
hand grip strength.
 Immunological test include total
lymphocyte count (TLC), delayed
cutaneous hypersensitivity,
measurement of thymus-dependent
lymphocytes, and lymphocyte
nitrogen assays.
Biochemical Assessment Methods for
other Nutrients such as Vitamins and
Minerals
2. Iron status
a. Three stages of the development iron-
deficiency anemia
1. Iron depletion
Characterized by progressive reduction in the
amount of storage iron in the liver. Levels of
transport iron and stores reflected by a fall in
serum ferritin concentrations.
2. Iron-deficient erythropoiesis
Complete exhaustion of iron stores; thus the
plasma iron supply to the erythropoitic cells
is reduced and decreases in transferrin
saturation occur but the erythrocyte
photoporphyrin concentrations increase. Hb
levels decline slightly and exercise
performance is reduced.
3.Iron-deficiency anemia
Final stage of iron deficiency; caused by
exhaustion of iron stores and declining levels
of circulating iron; microcytic, hypochromic
anemia. Reduced concentration of HB in
RBC, hematocrit and red cell indices.
F. Mean cell Hb
1. Refers to the Hb content of the
individual RBC.
2. Calculation
MCH (fL)= Hemoglobin (g/L) / Red blood
cell count (1012/L)
G. Serum iron, TIBC, and transferrin
saturation
1. Serum iron, TIBC, and transferrin
saturation differentiates between nutritional
deficiencies of iron and iron deficits arising
from chronic infections, inflammation, or
chronic neoplastic diseases.
2. Concentrations of serum iron and total
iron-binding capacity reflect the iron in
transit from the reticulo-endothelial system to
the bone marrow. Serum iron is a measure of
the number of atoms of iron bound to the iron
transport protein transferrin. Serum iron and
TBIC are determined simultaneously.
3. Calculations
Transferrin saturation (%) = Serum iron
(umol/L) x 100 / TIBC (umol/L)
H. Serum ferritin - The only iron status
index that can reflect a deficient, excess, and
normal iron status.
I. Erythrocyte protoporphyrin
Protoporphyrin is a precursor of
heme and occurs in erythrocytes in
very low concentrations. Provides
the same information as percentage
 transferrin saturation but is a more
stable measurement and responds
more gradually to changes in the iron
supply to the marrow.
D. Serum retinyl ester concentrations
Elevated concentrations of serum retinyl
esters observed after chronic ingestion of
high levels of vitamin A and in liver disease.
E. Serum carotenoids concentrations -
Reflect the current dietary intake of
carotenoids such as beta-carotene, lycopene,
and various hydroxylated carotenoids.
F. Relative dose response - A test used in
the estimation of liver stores of vitamin A and
can be used to identify those individuals with
marginal vitamin A deficiency.
G. Rapid dark adaptation test - Used to
assess nightblindness
H. Conjunctival impression cytology -
Detects early physiological changes
occurring in VAD.
4. Vitamin D status
a. Serum 25-hydroxyvitamin D
concentrations
 Most useful index of vitamin D status
in humans because it reflects the
amount of vitamin D in the liver
which is the major tissue store of
vitamin . Cut-off point for 25-OH
values indicative of vitamin D
deficiency is poorly defined. In
general, concentrations below 3.0
ng/mL (7.5 nmol/L) have been
associated with clinical signs of
vitamin D deficiency.
B. Serum alkaline phosphatase activity
 An indirect measure of vitamin D
status. Activity increases in
osteomalacia in adults and childhood
rickets.
C. Calcium and phosphorous
concentrations in serum and urine
  Total serum calcium is useful for
identifying possible cases of vitamin
D intoxication.
5.Vitamin E status
A. Serum tocopherol concentrations
 Most frequently used index of
vitamin E; a ratio of 0.6 mg total
tocopherols per gram of total serum
lipids indicates adequate vitamin E
status.
B. Tissue tocoperol concentration
 Analysis of liver biopsy or adipose
tissue samples is useful index of body
stores of vitamin E and thus, long-
term vitamin E status. But the method
is invasive and not suitable for large
population studies.
6. Vitamin C status
a. Serum ascorbic acid concentrations
 Most frequently used and practical
index of vitamin C status. Not used to
identify persons regularly consuming
low ascorbic acid intakes. But it
reflect body ascorbic acid content.
B. Leukocyte ascorbic acid concentrations
 more reliable index of tissue stores of
ascorbic acid; less responsive to short
term fluctuations in recent vitamin C
intakes than serum. Not widely used
as an index of ascorbic acid status.
C. Urinary excretion of ascorbic acid and
metabolites
 Reflects recent dietary intake. Levels
in the urine decline with increasing
depletion of vitamin C until levels are
undetectable particularly in persons
with scurvy. Not a very sensitive
index of ascorbic acid status.
D. Salivary ascorbic acid concentrations
 Not a promising tests even if its
noninvasive and simple to perform.
Ascorbic acid concentrations in the
saliva are low and change very little
and they are not corrected with
vitamin C intake.
7. Thiamine status
a. Erythrocyte transketolase activity
(ETKA)
 Transketolase is a thiamin
pyrophosphate-dependent enzyme.
Measurement of the activity of this
enzyme is used as an index of thiamin
nutritional status as the erythrocytes
are among the first tissues to be
affected by thiamin depletion.
b. Urinary thiamin excretion
 Thiamine levels in the urine do not
adequately reflect body stores but
provides an index of the dietary
intake. A thiamin load test has also
been used as an index of thiamin
status. Excretion of thiamin in a
fourhour period after the parenteral
administration of 5 mg of thiamin is
measured. If subjects are deficient in
thiamin, usually less than 20 ug of the
5 mg thiamin load during the four-
hour period is excreted.
8. Riboflavin status
A. Erythrocyte glutathione reductase
activity coefficient
 A useful and sensitive measure of
impaired riboflavin status.
Glutathione reductase is a
nicotinamide adenine dinucleotide
phosphate (NADP)- and FAD-
dependent enzyme, and is the major
erythrocytes. It catalyzes the
oxidative cleavage of the disulfide
bond of oxidized glutathione.
B.Urinary riboflavin excretion
 Reflects recent dietary intake than
body stores.
9. Niacin status
 Urinary excretion of N’-
methylnicotinamide and N’-methyl-
2-pyridone-5- carboxylamide are
major end-products of niacin
metabolism in humans. Test is not
appropriate for pregnant subjects and
diabetic patients. Not very specific
indices of niacin deficiency since
excretion of both in the urine is also
reduced in subjects with generalized
malnutrition. In normal healthy
adults, ratios range from 1.3 to 4.0
values below 1.0 indicate niacin
deficiency.
10. Vitamin B6 status
a. Plasma pyridoxal-5’-phosphate (PLP)
concentrations
 Provide a direct measure of the active
coenzyme and reflect tissue levels of
vitamin B6 in healthy, non-pregnant
persons.
b.Urinary excretion levels and erythrocyte
aminotransferase activities
 Reflect recent dietary intakes of
vitamin B6; tryptophan load test is a
functional test used to provide an
indirect measure of tissue vitamin B6
status.
11. Folate status
a. Serum folate levels reflect folate
balance, fluctuate rapidly with recent
changes in folate intake, and provide
no information on the size of tissue
folate stores. A serum folate value of
less than 3 ng/mL (6.8 nmo/L)
indicates negative folate balance
b. Erythrocyte folate concentrations is
estimated by measuring erythrocyte
folate concentrations which fall in
subjects in persistent negative folate
balance.
12. Vitamin B12 status
 Vitamin B12 deficiency due to poor
dietary intake is rare. Schilling test is
often used to ascertain whether
malabsorption is the cause of the
deficiency.
13. Calcium status
a. Serum calcium concentrations
 Low levels of serum calcium occur
after prolonged periods of deprivation
or poor absorption. Serum Ca
concentrations in normal healthy
adults range from 8.8 to 10.6 mg/dL
(2.20 to 2.64 mmol/L). It is used to
identify vitamin D intoxication.
b.Serum ionized Ca concentrations “elimination” is a median value of
iodine concentration of 100 ug/L, i.e
 Serum ionized Ca is the 50% of the samples should be above
physiologically active form of Ca. 100 ug/L and not more than 20% of
Ionized Ca occur in the samples should be below 50 ug/L.
hypoparathyroidism and rickets and
results to neuromuscular irritability.
C.Radiogrammetry
 Measures the thickness and the
diameter of the cortex of the
metacarpals or radius on standard
anterior-posterior roentgenograms of
the hand. Serial measurements are
used to monitor changes in cortical
bone volume. This does not
accurately reflect the total amount of
bone present.
14. Phosphorus status
 Serum phosphorus concentrations
Phosphorus deficiency due to poor
dietary intake is rare. Serum
phosphorus is the most frequently
used index but it has a low specificity
and sensitivity.
15. Magnesium status
Serum Mg concentrations
 Most frequently used index of Mg
status. The mean serum Mg
concentrations in adult humans is
approximately 0.85 mmol. Mg
deficiency develops in association
with disease states such as severe
malabsorption, GIT disorders,
alcoholism, cirrhosis, severe burns,
and congestive heart failure or
prolonged diuretic therapy.
16. Iodine status
 The criteria below is used to classify
IDD problem into different degrees of
public health significance. The
indicator of iodine deficiency
CLINICAL ASSESSMENT
A. Clinical assessment
 Consists of a routine medical history and
an examination to detect physical signs
and symptoms. Most useful during the
advanced stages of nutritional depletion,
when overt disease is present.
 Medical history includes a description of
the patient, and the relevant
environmental, social and family factors
and specific data on the medical history
of the patient and his/her family.
 Physical examination is defined by
Jelliffe (1966), “examines those changes
, believed to be related to inadequate
nutrition, that can be seen or felt in the
superficial epithelial tissue, especially the
skin, eyes, hair, and buccal mucosa, or in
organs near the surface of the body, e.g.
parotid and thyroid glands”.
 Deals with the examination of changes
that can be seen or felt in superficial
tissues, such as skin, eyes, hair, among
others.
A. Classifications of physical signs
most often associated with
malnutrition according to the
world health organization (WHO)
Group1: signs that are considered of
value in nutritional assessment or signs
indicating a probable deficiency of one or
more nutrients; often associated with
nutritional deficiency status. Signs of
malnutrition may be mixed and may be
due to the deficiency of two or more
micronutrients.
Group 2: signs that indicate probable
long-term malnutrition in combination
with other factors. They may be related to
malnutrition but are often found in
populations of developing countries
where other health and environmental
problems such as poverty and illiteracy
are co-existent.
Group 3: signs that have no relation to
malnutrition although they may be
similar to physical signs found in persons
with malnutrition and must be carefully
delineated from them.
B. Major problems encountered in the
clinical assessments of nutritional
status
1. Their low general prevalence in
developed countries in high risk groups.
2. The non-specificity of clinical signs in
most populations, particularly developed
countries.
3. The substantial differences in the
prevalence of physical signs recorded by
different examiners
E. Reasons for including physical
examinations in nutrition surveys
1. It may reveal evidence of certain
nutritional deficiencies which will not be
detected by dietary or laboratory
methods.
2. The identification of even a few cases
of clear-cut nutritional deficiency may be
particularly revealing and provide a clue
to other pockets of malnutrition in a
community.
 Vitamin C Deficiency
3. The nutritional examination may
reveal signs of a host of other diseases
which merit diagnosis and treatment.
F. Limitations of the physical examination Vitamin D Deficiency
1. non-specificity of the physical signs
2. Presence of multiple physical signs
3. Signs may be two-directional
4. Examiner inconsistencies
5. Variation in the pattern of physical
signs

Vitamin B6 Deficiency Vitamin D

Vitamin B2 deficiency Vitamin C Deficiency

Vitamin B2 deficiency Vitamin B12 Deficiency

H. PREDOMINANT CLINICIAL
SYMPTOMS OF COMMON
NUTRITIONAL PROBLEMS

C. Suggested interpretative Guide for

Endemic Goiter
1. Endemic goiter can be said to exist as a
significant public health problem where
a. At least 5 % of adolescents or pre-
adolescents have goiter of grade 1 or above,
or
 b. At least 30% of adults have goiter or Gr SUMMARY ( Predominant Clinical
1b or above Symptoms of Common Nutritional
Problems)
2. Intervention programs are indicated
when 5% of the girls have an enlarged  protein-energy malnutrition-
thyroid (Gr 1b and above).  Vitamin A deficiency
 Anemia
Goiter  Goiter
 Highschool children – age group when  Ariboflavonis
goiter becomes clinically diagnosable  Beriberi
 An endemic area is one wherein 10% of  Hypertension
the population has goiter I.Physical signs and nutritional terms
associated with malnutrition
1. General appearance
a. Apathy- unreactive, unresponsive,
disinterested, and inattentive to surroundings
b. Clinical marasmus- pronounced wasting
of subcutaneous fat without edema; apathy
may be present; face and eyes of the child
may be appear unusually bright due to the
combination of wasting and prominence of
5.Ariboflavonis the eyes; underdeveloped in relation to age
 Magenta red tongue and there may or may not be associated with
 Sores at the angels of the mouth and folds hair changes such as dyspigmentation,
of the nose thinness, easily pluckable, or signs of
avitaminosis
6. Beriberi
c. Irritability- hyperresponsive, excessive or
 Muscle weakness overreaction to minor stimuli, particularly
 Fatigability manifest through crying or unusual indication
 Heart enlargement of fear as a result of minor or relatively
 Tachycardia insignificant happenings
 Edema (wet type)
d. Kwashiorkor- pitting edema on the
7. Hypertension pretibial region, underweight, undersize,
underdeveloped for age; muscular wasting
may be present by masked by edema; hair
becomes thin, easily pluckable with flag sign,
and change in texture to silken, sparse hair
e. Pallor- paleness and loss of color of skin,
nail buds, mucosa and lips
f. Prekwashiorkor- an underweight,
undersized, underdeveloped child, without
the evident pronounced wasting present in
marasmus.
2. Hair
a. Dry Staring- dry, wirelike, unkempt, stiff
hair, often brittle, sometimes may exhibit
some leaching of the normal color
b. Dyspigmentation- definite change from
normal pigment of the hair; includes both
change of pigment usually lightening of color
and pepigmentation
c. Easily pluckable- easily pluckable hair is
that in which the shafts are readily removed
with minimum fug when a few strands are
grasped between the finger and thumb and
gently pulled.
3. Skin
a. Crackled skin- definite scales larger in
size seen in xerosis; non- nutritional in origin
b. Dependent edema- presence of
abnormally large amounts of fluid in the
intercellular tissue spaces of the body
c. Dermatitis, with desquamation, or
crazy-pavement type
d. Follicular hyperkeratosis- similar to
gooseflesh which is seen on the chilling; but
it is not generalized and does not disappear
with brisk rubbing of the skin; skin is rough
with papillae formed by the keratotic plugs
which project from the hair follices;
surrounding skin is dry and lacks moisture or
oilness. e.
e. Pellagrous dermatitis- symmetrical
lesions typical of acute or chronic, mild or
severe pellagara; lesions are red, often
swollen or blistered skin like sunbum,
pigmented, scaly over exposed areas
f. Purpura or petechia- small localized
extravasations of blood, red or purplish in
color, depending on time elapsed since
formation
g. Xerosis- clinical term used o describe a
dry and crinkled skin which is accentuated by
punching the skin parallel to its surface
4. Skeletal
a. Bowleg- an outward curve of one or both
legs at or below the knee
b. Costochondral beading- palpable and
visible enlargement of the costochondral
junctions
c. Cranial bossing- abnormal prominence or
protrusion of frontal of parietal areas
d. Enlarged joints- when the ends of the
long bones are enlarged; i.e. wrist, ankles,
knees
e. Wingled scapula- a scapula having a
prominent vertebral border
5 . Muscle
Muscle wasting- exhibited by unusual
prominence off bony skeleton undue degree
of folding of the skin of the buttocks, or the
abnormal flabby feel of the child with poor
muscle tone
6. Eyes
a. Bitot’s spots- small circumscribed
grayish or yellowish gray, dull, dry, foamy
superficial lesions of the conjunctiva
b. Blepharitis- inflammation of the eyelids
c. Keratomalacia- Softening of the cornea
d. Thickened opaque bulbar conjunctivae-
results in glazed, porcelain-like appearance,
obscuring the vascularity
e. Xerosis conjunctivae- conjunctivae
appear dull, lusterluss, and exhibit a striated
or roughened surface
7. Face
a. Angular lesions- present bilaterally when
mouth is held half open; may appear as pink
or moist whitish macerated angular lesions a. Parotid enlargement- check by palpation
which blur the muccocutaneous junction with fingers upward and backward toward
the ear and if bilateral
b. Angular scars- scars at the angles, which,
if recent, may be pink; if old, may appear b. Thyroid enlargement- a visually
blanced. perceptible enlargement definitely palpable
with or without swallowing is noted.
c. Cheilosis- lips are swollen, tense or puffy
and the buccal mucosa extends out onto the
lips; vertical fissuring of the lips
11. Organs
d. Nasolabial seborrhea- greasy yellowish
scalling or filiform excrescenses in the a. hepatomegaly- liver edges more than 2
nasolabial area which become more cm below the costal magrin
pronounced on slight scratching with the b. Splenomegaly- spleen is palpable
fingemail or a tounge blade
8.Mouth
SUMMARY ( Physical signs and nutritional
a. Filiform papillary atrophy- filiform terms associated with malnutrition)
papillae exceeding low or absent giving the
tongue a smooth appearance which remains  General appearance
after scraping slightly with an applicator  Hair
stick; could be mild (1/4 to the tongue  Skin
particularly on the tip and lateral margins),  Skeletal
moderate (1/4 to ¾ of the tongue, and severe  Muscle
(involves ¾ of the tongue)  Eyes
 Face
b. Glossitis- any increase in redness,  Mouth
fissuring or swelling with color change or  Teeth
diffuse involvement of mucosa  Glands
c. Magenta colored- the color of alkaline
phenophtalein
d. Swollen gums- swollen red interdental
papillae with more than one papilla involved
9. Teeth
a. Carious teeth- molecular decay of a bone
in which it becomes thinned and dark and
gradually breaks down with the formation of
pus
b. Fluorosis- opaque paper- white areas in
the enamel of the tooth, ranging in size from
few flecks to entire enamel surface
10. Glands