MODULE 1

NUTRITION CARE PROCESS

CHAPTER 1 NUTRITIONAL SCREENING AND ASSESSMENT

Patient Assessment and Diet Planning (Standard Operating Procedures)

• Ask patients about their age, height, weight (any weight

changes) and calculate their BMI and their Ideal Body
weight (IBW).
• Write down the medical Diagnosis upon interviewing the
patient.
Patient • Assess the patient‘s food habits and dietary intake from
Step 1
Assessment all the food groups.
• Question about eating out, use of carbonated beverages,
type of wheat, oil, sugar they use etc.
• Assess any GI problems.
• Have a general idea of their routine.
• How much water consumed all day.

• Know the Type and Mechanism of Diet.

• Know how much calories per day the patient needs.
Dietary
Step 2 • Divide appropriate servings from each food group
Recommendations
according to the calories given.
• Calculate the recommended fluid intake.

• Develop a diet plan, balancing the servings from each

Step 3 Eating Plan
food group.

Dietary
• Educate the patient about what to eat n what not to.
Step 4 Guidelines/
• Restrict any food item as per the patient’s diagnosis.
Instructions

• Food Remedies- Natural foods used as a medicine and

incorporated in the diet in different ways.
Step 5
Letterhead • Some laboratory tests can be advised if necessary.
• Food Supplements (Powder/liquid or Tablet/Capsule).
• Products Name and Brand that is being advised.

• Patient called up for a follow up usually after a 1- 2

Step 6 Follow – up
week period.

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Nutrition Screening:

This is the first step in identifying subjects who may be at nutritional risk or potentially at risk, and
who may benefit from appropriate nutritional intervention. It is a rapid, simple and general
procedure used by nursing, medical, or other staff on first contact with the subject so that clear
guidelines for action can be implemented and appropriate nutritional advice provided. Some subjects
may just need help and advice with eating and drinking; others may need to be referred for more
expert advice. Screening may need to be repeated regularly as a subject‘s clinical condition and
nutritional problems can change. It is particularly important to re-assess subjects identified at risk as
they move through care settings. It is always better to prevent or detect problems early by screening
than discover serious problems later.

Medical History:

In clinical medicine, the patient's past and present which may contain relevant information bearing
on their health past, present, and future? The medical history, being an account of all medical events
and problems a person has experienced is an important tool in the management of the patient.

Objective:

To identify patients who need nutritional therapy to restore or maintain nutritional status.

Subjective Global Assessment (SGA):

The subjective global assessment is multi-method indicator of nutritional status. The two basic
components of SGA are a clinical interview and a physical examination. The Subjective Global
Assessment gives a broad perspective of malnutrition. Other available parameters should be
reviewed for their impact on the patient‘s overall health status, such as results from laboratory and a
thorough physical examination.

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Clinical Interviews: Because the patient‘s ‗mental capacity or emotional state‘ can limit or
interfere with the interview process, the clinician may need to repeat or rephrase interview questions
when probing for relevant information or use substitute information provided by someone who has
closely observed the patient. The clinical interview should obtain subjective information in five
categories each of which is explained below with sample questions.

Body Weight: Loss of weight is a significant predictor of nutritional status. It is important to note
if losses have occurred over the past six months or last two weeks. Gradual weight loss within the
last six months may indicate either a chronic progressive condition or simply a change in diet.
Significant losses over the last 2 weeks; however, may indicate a higher risk of malnutrition. (Take
weight history using the following questions)

• What is your usual body weight?

• Have you lost weight in the last six months?
• Do you know how much?
• For patients not sure of the numerical amount of weight loss, a clinician might ask:
• Did you have to change the size of your clothes, or the tightness of your belt?
• Have your acquaintances mentioned that you look thinner/chubbier than before?

Changes in Eating Patterns:

• Have you changed your eating habits?

• What type of foods have you been eating?
• Are your meals the same as those of other people in your house?
• Are you eating solid foods or just liquids?
• What about the amount of food you eat? Has that changed?
• For how long have these changes been occurring?

Gastrointestinal Symptoms: Patients with gastrointestinal signs and symptoms that persist
more than 15 days may be at risk for malnutrition.

• Have you been vomiting?

• Do you vomit every day or so? If so, how long has this been happening?
• Do you feel nauseous?
• Do you have diarrhea?
• How many episodes per day do you get? How long has this persisted?
• Have you had anorexia or bulimia?

Functional Capacity or Energy levels:

Sick patients may be weak and lack the motivation to maintain their physical activities. They may
get tired easily. Consequently, patients should be asked about their everyday physical routine.

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 • Are you working normally?
• How much time do you spend in bed or sofa?
• How many chores are you doing now compared to the number of chores you normally
do?

Disease Activity and Impact:

Many illnesses change the body‘s metabolic output. In majority of the situations, a sick patient has
increased caloric and protein demands, some illnesses may lower metabolic activity and require
reduced nutrients. The specific diseased state of the patient should be categorized by the clinician as
follows:

• Low stress, such as a patient with an inguinal hernia and no other disease.
• Moderate stress, such as a diabetic patient with pneumonia.
• High stress, such as a patient with serve peritonitis.

Laboratory Data:

Biochemical data analysis

Physical Examination:

For each specify: 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe

• Loss of subcutaneous fat

• Loss of body mass
• Ankle edema
• Sacral edema
• Ascites

SGA Rating:

Well Nourished A
Malnourished B
Severely Malnourished C

Source: https://www.accc-cancer.org/oncology_issues/supplements/Scored-Patient-Generated-
Subjective-Global-Assessment-PG-SGA.pdf

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Nutritional Assessment Tools:

Nutritional Assessment is the interpretation of anthropometric, biochemical (laboratory), clinical and

dietary data to determine whether a person or groups of people are well nourished or malnourished
(over-nourished or under-nourished).

Nutritional Assessment can be done using the ABCD methods. These refer to the following:

• Anthropometry
• Biochemical Methods
• Clinical Methods
• Dietary Methods

Anthropometric Measurements:

The word anthropometry comes from two words: -Anthropo means human and -metry means
measurement ‘. In your community you will be able to use anthropometric measurements to assess
either growth or change in the body composition of the people you are responsible for. The different
measurements taken to assess growth and body composition are presented below:

Height:

Measuring Height Using a Stadiometer:

• Ensure the floor surface is even and firm.

• Have subject remove shoes and stand up straight with heels together, and with heels, buttocks
and shoulders pressed against the stadiometer.
• Arms should hang freely with palms facing thighs.
• Take the measurement with the subject standing tall, looking straight ahead with the head
upright and not tilted backwards.
• Make sure the subject's heels stay flat on the floor.
• Lower the measure on the stadiometer until it makes contact with the top of the head.
• Record standing height to the nearest centimeter.

Measuring Height Using Demi Span:

• Demi span (half-arm span) is the distance from the midline at the sternal notch to the web
between the middle and ring fingers along outstretched arm. Height is then calculated from a
standard formula.
• Locate and mark the midpoint of the sternal notch with the pen. Ask the patient to place the
left arm in a horizontal position.
• Check that the patient’s arm is horizontal and in line with shoulders.

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 • Using the tape measure, measure distance from mark on the midline at the sternal notch to
the web between the middle and ring fingers.
• Check that arm is flat and wrist is straight. Take reading in cm.

Measuring Height Using Half Demi Span:

Half arm-span is the distance from the midline at the sternal notch to the tip of the middle finger.
Height is then calculated by doubling the half arm-span.

• Locate and mark the edge of the right collar bone (in the sternal notch) with the pen.
• Ask the patient to place the non-dominant arm in a horizontal position.
• Check that the patient‘s arm is horizontal and in line with shoulders.
• Using the tape measure, measure distance from mark on the midline at the sternal notch to
the tip of the middle finger.
• Check that arm is flat and wrist is straight.
• Take reading in cm.

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Measuring Height Using Knee Height:

Knee height is one method used to determine statue in the bed- or chair-bound patient and is
measured using a sliding knee height caliper. The patient must be able to bend both the knee and the
ankle of one leg to 90-degree angles.

Have the subject bend the knee and ankle of one leg at a 90-degree angle while lying supine or
sitting on a table with legs hanging off the table. Place the fixed blade of the knee caliper under the
heel of the foot in line with the ankle bone. Place the fixed blade of the caliper on the anterior
surface of the thigh about 3.0 cm above the patella.

Be sure the shaft of the caliper is in line with and parallel to the long bone in the lower leg (tibia)
and is over the ankle bone (lateral malleolus). Apply pressure to compress the tissue. Record the
measurement to the nearest 0.1 cm. Take two measurements in immediate succession.

They should agree within 0.5 cm. Use the average of these two measurements and the patient ‘s
chronological age in the population and gender-specific equations in the table on the right to
calculate the subject ‘s stature.

The value calculated from the selected equation is an estimate of the person ‘s true stature. The 95
percent confidence for this estimate is plus or minus twice the SEE value for each equation.

Weight Measurement:

Weight should be measured in all participants, except pregnant women, wheelchair bound
individuals, or persons who have difficulty standing steady.

Setting up Scale at the Examination Site:

The scale should be placed on a hard-floor surface (not on a floor which is carpeted or otherwise
covered with soft material). If there is no such floor available, a hard-wooden platform should be
placed under the scale. A carpenter's level should be used to verify that the surface on which the
scale is placed is horizontal.

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Calibration of Scale:

Calibration should occur at the beginning and end of each examining day. The scale is balanced with
both sliding weights at zero and the balance bar aligned. The scale is checked using the standardized
weights and calibration is corrected if the error is greater than 0.2 kg. The results of the checking and
the recalibrations are recorded in a log book.

Normal Weighing Procedure:

Participants are asked to remove their heavy outer garments (jacket, coat, trousers, skirts, etc.) and
shoes. If subjects refuse to remove trousers or skirt, at least make them empty their pockets and
record the fact in the data collection form.

The participant stands in the center of the platform, weight distributed evenly to both feet. Standing
off-center may affect measurement.

Posture of the subject during the weight measurement is (1) the weights are moved until the beam
balances (the arrows are aligned). (2) Moving the weights to balance the beam

The weight is recorded to the resolution of the scale (the nearest 0.1 kg or 0.2 kg).

• Weighing procedure for heavily overweight persons

• If the participant is heavily overweight, i.e. weighs more than the upper limit of the scale,
this fact should be noted in the data collection form, together with the upper limit of the
scale.
• Self-reported Weight: Self-reported weights are not acceptable, even if the participant is
immobile or refuses to be weighed.

Waist Circumference Measurement:

Setting up the Place for the Waist Circumference Measurement:

The full body length mirror is placed against the wall or if the mirror stands on its own feet next to
the measurement place. Using the carpenter level, it should be verified that grid lines on the mirror
are horizontal.

Checking of Tape:

The length of the measuring tape is checked with the calibrated length rod (usually the 150 cm one)
at least once per month. If the measuring tape is stretched it should be replaced.

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Position of Waist Circumference Measurement:

Waist circumference should be measured at a level midway between the lower rib margin and iliac
crest with the tape all around the body in horizontal position

Waist Circumference Measurement Procedure:

Participants are asked to remove their clothes, except for light underwear. If this is not possible, for
example due to cultural reasons, the alternative is to measure the circumference on the subject
without heavy outer garments and record this fact in the data collection form. Tight clothing,
including the belt, should be loosened and the pockets emptied.

The measurer should stand at the side of the participant in order to have a clear view of the mirror.

Participants should be standing with their feet fairly close together (about 12-15 cm) with their
weight equally distributed to each leg. Participants are asked to breathe normally; the reading of the
measurement should be taken at the end of gentle exhaling. This will prevent subjects from
contracting their abdominal muscles or from holding their breath.

The measuring tape is held firmly, ensuring its horizontal position. Use the grid lines on the mirror
to verify that the tape position is horizontal all around the waist. The tape should be loose enough to
allow the observer to place one finger between the tape and the subject's body.

Self-Reported Waist Circumference:

If the participant is immobile or refuses to have his/her waist circumference measured, this fact
should be recorded in the data collection form. Self-reported waist circumference is not acceptable
as a substitute.

Waist Circumference Exceeds the Length of the Tape:

If the waist circumference exceeds the length of the tape, this fact should be recorded in the data
collection form together with the maximum length of the tape

Basic Nutrition Calculations:

Ideal Body Weight:

A weight that is believed to be maximally healthful for a person, based chiefly on height but
modified by factors such as gender, age, build, and degree of muscular development.

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Calculation of Ideal Body Weight:

IBW for Men above 5 feet = 106 lb for first 5’ + 6 lb x (additional inches above 5 feet)
IBW for Men below 5 feet = 106 – 6 x (inches below 5 feet)

IBW for Women above 5 feet= 100 lb for first 5 feet + 5 lb for each additional inch
IBW for Women below 5 feet = 100 – 5 x (inches below 5 feet)

Example; IBW for a male with height 4’9’’ would be calculated as under
Calculating inches less than fifth foot (12-9=3)
106 – (6*3) = 124 lb. or 56.36 Kg

IBW for Paeds is performed over growth charts (available at the end of the chapter).

Body Mass Index (BMI):

An approximate measure of whether someone is over- or underweight, calculated by dividing their

weight in kilograms by the square of their height in meters.

Body Mass Index (BMI) Calculation:

For Adults BMI = Weight (kg) / Height (m) 2

[cm to meter = x (cm)/100]

For Paeds BMI = Weight (lb) / Height (inches)² x 703

Obesity Adjustment: [(Actual BW – IBW) x 0.25 + IBW]

Standard BMI Women Men

Under weight <18.5 <18.5

Desirable or Healthy weight 18.5-24 20-25

Overweight 25-30 25-30

Obese grade I 30-35 30-35

Obese grade II 35-40 35-40

Obese grade III 40-45 45-50

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Wrist Circumference:

Body frame size is determined by wrist circumference in relation to height. Gender makes also a
difference. For example, an adult male who has a body height over 5‘5″ and a wrist size of 7″, has a
medium frame size. An adult female who has a body height of 5‘4″ and a wrist size of 6.5″, has a
large frame.

Female Wrist Measurements:

Height less than 5’2″ (157 cm)

Small = wrist size less than 5.5″ (14 cm)

Medium = wrist size 5.5″ to 5.75″ (14 to 14.6 cm)
Large = wrist size over 5.75″ (14.6 cm)

Height 5’2″ to 5’5″ (157 to 165 cm)

Small = wrist size less than 6″ (15.2 cm)

Medium = wrist size 6″ to 6.25″ (15.2 to 15.9 cm)
Large = wrist size over 6.25″ (15.9 cm)

Height more than 5’5″ (165 cm)

Small = wrist size less than 6.25″ (15.9 cm)

Medium = wrist size 6.25″ to 6.5″ (15.9 to 16.5 cm)
Large = wrist size over 6.5″ (16.5 cm)

Male Wrist Measurements:

Height more than 5’5″ (165 cm)

Small = wrist size 5.5″ to 6.5″ (14 to 16.5 cm)

Medium = wrist size 6.5″ to 7.5″ (16.5 cm to 19 cm)
Large = wrist size more than 7.5″ (19 cm)

Hip Circumference Measurement:

Position of Hip Circumference Measurement:

Hip circumference should be measured as the maximal circumference over the buttocks. The grid
lines on the mirror are used to verify that the tape position is horizontal all around the body.

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Hip Circumference Measurement Procedure:

Same as for waist circumference, except for tape position.

Self-Reported Hip Circumference:

If the participant is immobile or refuses to have his/her hip circumference measured, this fact should
be recorded in the data collection form. His/her self-reported hip circumference is not acceptable as
a substitute.

Hip Circumference Exceeds the Length of the Tape:

If the hip circumference exceeds the length of the tape, this fact together with the maximum length
of the tape, should be recorded in the data collection form.

Biochemical Measurements:

Biochemical measurements of such compounds as creatinine, albumin, retinol binding protein,

transferrin, and transthyretin provide a quantitative measure of nutritional status.

Creatinine: Biochemical measurements of the concentration of creatinine in serum or the excretion

of creatinine in urine provides an assessment of total body muscle mass for individuals with normal
renal function. Muscle mass is a reflection of proper protein nutrition.

Albumin: Albumin is the protein in highest concentration in plasma, and has a half-life of 18 to 20
days. Hypoalbuminemia may be an indicator of protein deficiency.

Retinol-binding protein correlates well with protein-energy status of the patient.

Transferrin is the protein that acts as a carrier protein for iron. It has a half-life of 8 days, which
makes it a sensitive marker of recent protein-energy nutritional status.

Transthyretin, or TBPA, is the protein that acts as a carrier for thyroid hormones. Its short half-life
of 1-2 days makes it a sensitive marker for protein-energy nutritional status.

However, these protein concentrations are also affected by other physiological changes and disease
states of the patient, so their concentration must be carefully assessed for nutritional status. The use
of multiple biochemical measurements markers for nutritional status gives a more accurate picture of
nutritional status than relying upon the measurement of only one marker. Several indices use
multiple markers for calculating nutritional status.

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 NORMAL BLOOD CHEMISTRY
SERUM ELECTROLYTES
Na 135-147 mEq/L
K 3.5-5.5 mEq/l
Cl 95-106 mEq/L
Magnesium 1.8-3.6 mg/dL; 1.5-3.0 mEq/L
3-4.5 mg/dL; 1.8-2.3 mEq/L (adults)
Phosphorous
4-6.5 mg/dL; 2.3-3.8 mEq/L (children)
Calcium (total) 9-11 mg/dL; 4.5-5.5 mEq/L
Bicarbonate (total) 18-30 mEq/L
GLUCOSE
Fasting 70 and 99 mg/dL
Random >200 mg/dL
Serum Insulin Fasting: <25 mIU/L
2 hour after glucose administration: 16-166 mIU/L
Hyperglycemia >240 mg/dL
Hypoglycemia <70 mg/dL
RFTs
BUN 8-25 mg/dl
Creatinine 0.6-1.3 mg/dl
Globulin 20-35 g/L
LFTs
AST 0-35 IU/L
ALT 0-45 IU/L
Albumin 40-60 g/l
Bilirubin 2-17 µmol/l
PTT 10.9-12.5 sec.
Alk.Phos. 30-120 IU/L
CPK 30-220 IU/L
Uric Acid 2.7-7.3 mg/dl
Serum Iron 60-170 mg/dl
LIPID PROFILE
Triglyceride < 250 mg/dl
Cholesterol <225mg/dl (based on age)
LDL < 100 mg/dl
VLDL 2-30 mg/dl
HDL 40-50 mg/dl
Total Cholesterol 300-600 mg/dl

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 COMPLETE BLOOD COUNT (CBC)
Platelets 140-400 K/uL
WBC 5-10 K/uL
RBC 4-5.5 M/uL
Hb 12-17.4 g/dl
HCT 36%-52%
Total lymphocyte 1.2-3.3 x 1000 cells
Prothrombin time 11-14 seconds

Nitrogen balance is the biochemical measurements of the difference between nitrogen intake and
excretion. A positive nitrogen balance is recommended for therapy of certain disorders, such as
wound healing, as well as during periods of anabolism or growth. Since most nitrogen is excreted in
urine, nitrogen balance may be estimated by measurement of urinary urea nitrogen. Renal status will
affect this measurement and must be taken into consideration when using urinary urea nitrogen as an
assessment tool. Immuno-competence is also affected by nutritional status. Malnutrition is
associated with progressive decline of immune function. Total lymphocyte levels, T lymphocyte
levels, immunoglobulin levels, and complement levels are all affected by protein malnutrition. The
loss of immune competence will lead to infections. Candida and other opportunistic infections may
be acquired following the loss of immune competence due to malnutrition. The best assessment of
nutritional status is the use of a combination of biochemical measurements from several categories,
such as weight measurement, BMI, and biochemical markers. Albumin, transferrin, TBPA
(transthyretin), urine urea nitrogen, and immune markers all give quantitative measurements for the
assessment of nutritional status.

BLOOD TESTS FOR DETERMINING NUTRITIONAL STATUS

NUTRIENT LABORATORY TEST ACCEPTABLE LIMITS

MACRO NUTRIENTS
Carbohydrate Plasma Glucose 70-120 mg1/100ml2
Fat Serum cholesterol 140-220 mg/100ml
Serum triglycerides 60-150 mg/100ml
Visceral serum protein Above 6.5 gm3/100 ml
Protein Immune function: (total
lymphocyte count) Above 1200
FAT-SOLUBLE VITAMINS
Vitamin A Serum Vitamin A 20-45 ug4/100 ml
Serum carotene 40-300 ug/100 ml
Vitamin D Serum alkaline phosphate 35-145 IU5/L6

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 Plasma 25 hydroxy
cholecalciferol 10-40 IU/L
Vitamin E Plasma Vitamin E Above 0.6 mg/100 ml
Vitamin K Prothrombin time 12 seconds
WATER-SOLUBLE VITAMINS
Vitamin C Serum ascorbic acid Above 0.3/100 ml
B COMPLEX VITAMINS
Thiamin Red blood cell transketolase 0-15 %
Riboflavin Red blood cell glutathione Below 1.2
Niacin Urinary nitrogen* Above 0.6 mg/gm creatinine
Vitamin B6 Tryptophan load* Below 50 ug/24 hrs
Vitamin B12 Serum B12 Above 200 pg/100 ml
Folacin Serum Folacin Above 6.0 ng/100 ml
Iodine Serum protein bound iodine (PBI) 4.8-8.0 ug/100 ml
Iron Hemoglobin Male 14 mg/100 ml
Female 12 mg/100 ml
Hematocrit Male 44%
Female 33%
Calcium Serum Calcium 9.0-11.0 mg/100 ml
Phosphorus Serum phosphorus 2.5-4.5 mg/100 ml
Magnesium Serum magnesium 1.3-2.0 mEq/L
Sodium Serum sodium 130-150 mEq/L
Potassium Serum potassium 3.5-5.0 mEq/L
Chloride Serum chloride 99-110 mEq/L
Zinc Plasma zinc 80-100 ug/100 ml

Clinical Examination:

Clinical methods of assessing nutritional status involve checking signs of deficiency at specific
places on the body or asking the patient whether they have any symptoms that might suggest
nutrient deficiency from the patient. Clinical signs of nutrient deficiency include: pallor (on the
palm of the hand or the conjunctiva of the eye), Bitot’s spots on the eyes, pitting edema, goiter and
severe visible wasting.

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 PHYSICAL INDICATORS OF NUTRITIONAL STATUS

Body Part Signs of Good Nutrition Signs of Malnutrition

Head to Neck
Shiny, lustrous, smooth Dull, dry, thin, wire like, sparse, scalp
Hair
healthy scalp rough and flaky.
Skin smooth, moist, with Pale or mottled, dark under eyes, swollen,
Face
uniform color. scaling or flakiness, lumpiness.
Dry membranes, redness, fissure at corners,
Eyes Bright, clear and moist. red rimmed, fine blood vessels or scars at
cornea.

Lips Smooth and pink. Red, swollen, lesions or fissures.

Deep red, slightly rough Scarlet or purplish color, raw, swollen and
Tongue
surface. smooth.
Straight, non-missing, no Cavities black, gray spots, erupting
Teeth
Overlap, without cavities. abnormally and missing.
Spongy, bleed easily, inflammation,
Gums Firm, pink, smooth no bleeding.
receded and atrophied.
Skin and Nails
Dry, flaky, scaling, ―gooseflesh, swollen,
Skin Smooth, moist, uniform color grayish, bruises due to capillary bleeding
under skin, no fat layer under skin.
Pink nail beds, smooth, firm, Brittle, ridged, pale nail beds, clubbed and
Nails
flexible and uniform shape. spoon shaped.
Glands
Front of neck and cheeks become swollen,
No thyroid enlargement, no
Glands lumps visible at parotid, goiter visible if
lumps at parotid juncture.
advanced hypothyroidism.
Muscle and Skeletal System
Flaccid, wasted muscle, weakness,
Good posture, firm well
tenderness, decreased reflexes, difficulty in
Muscle and developed muscle, good
walking. Children: beading ribs, swelling at
skeletal system mobility, no malformations of
end of bones, abnormal protrusion of
skeleton.
frontal or parietal areas
Internal Systems
Distended, enlarged abdomen, ascites,
Flat abdomen, liver not tender
Gastrointestinal hepatomegaly (enlarged liver) Children:
to palpate, normal size.
―potbelly
Pulse rate exceeds 100 beats/min, abnormal
Normal pulse rate, normal blood
Cardiovascular rhythm, blood pressure elevated, mental
pressure.
confusion and edema.

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Dietary Methods of Assessment:

Dietary Methods of Assessment include looking at past or current intakes of nutrients from food by
individuals or a group to determine their nutritional status. You can ask what the family or the
mother and the child have eaten over the past 24 hours and use this data to calculate the dietary
diversity score. Dietary diversity is a measure of the number of food groups consumed over a
reference period, usually 24 hours. Generally, there are six food groups that our body needs to have
every day.

Dietary History (24-hour Intake Record):

Food
Preferences Food Acceptable Food Dislikes Food Allergies Other

Special Occasion
Meals: Usual Time Serving Size Where weekends/holidays
Breakfast
Lunch
Dinner/Supper
Snacks

Vitamin, Mineral Supplements taken: Kind ________________ Amount: _______________

Reason for taking: ___________________________________________________________

Usual preparation method (bake, boil, broil, fry etc.)

Meats: ____________________________ Vegetables: _______________________________

Diet History (24 Hour Recall):

Meals Timings Food Items Amount Kcals

Breakfast
Mid-Day Snack
Lunch
Evening Snack
Dinner
Bed Time

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Ask about Meals

• Do you skip your meals? If yes then which one.

• How many times a week do you eat the following meals?

Meal Frequency
Breakfast
Lunch
Evening Tea
Dinner

Food Frequency According to Food Groups:

How many times a week do you eat the following foods?

Food Groups Number of times a day Weekly Intake

Milk and Milk Products

(milk, yogurt, lassi, cream and desserts prepared with milk)
Meat and Meat Substitute
(egg, meat, poultry, fish)

Vegetables

Fruits

Bread and Cereals

Fats and Oils
(type of ghee oil, butter, margarine)

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Some Particular Questions to Ask in Diet History:

• Which type of milk and yogurt do you use? Fresh or tetra packed.
• Which type of flour do you use? Whole wheat (Chakki) or added white flour.
• Which fat do you use (desi/banaspati ghee, vegetables oil, hydrogenated fat, butter/ makhan?
• How often do you take carbonated drinks?
• How often do you dine out?
• Are you taking any nutritional supplement/s? If yes, then which one/s?
• Do you smoke?
• Have you been on a special diet or use special formulas?

(Ask especially when the patient is trying to lose weight)

ASSIGNMENTS

1. Self-Calculation practice according to SGA (one male and one female).

2. Take 24 hr Dietary Recall of a person.

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CHAPTER 2 ________________ DIETARY RECOMMENDATIONS
AND EATING PLAN

CALORIC, PROTEIN and FLUID ESTIMATION METHODS:

There are a number of methods which are applied in field to estimate a person’s caloric needs,
protein requirements and Fluids, few of them are mentioned below

1. Calorie Estimation:

METHOD 1 (Most Accurate and Authentic Estimation):

For Underweight patients use Harris-Benedict Equation:

BEE for Male = 66.5 + (13.7 ×wt.) + (5 × height) – (6.8 × age)

BEE for Female = 655.1 + (9.6 × wt.) + (1.85 × height) – (4.7 × age)

Total caloric requirement = BEE x Activity factor x Injury factor

*Add activity factor based on the level of activity performed

*Use appropriate stress factor for diseases

For Healthy, Obese, Overweight patients use Mifflin Jeors Equation:

BEE for Male = (9.99 ×wt.) + (6.25 × height) – (4.92 × age) + 5

BEE for Female = (9.99 ×wt.) + (6.25 × height) – (4.92 × age) - 161

METHOD 2 (Recommendations from Researches):

Stress Level Kcal/ kg BW

Normal 30-35
Elective Surgery 35-40
Severe Surgery 30-40
Extensive Burn or Trauma 44-55

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METHOD 3 (Energy needs based on Weight and Activity):

Weight Sedentary Moderate Active

Over weight 20-25Kcal/kg 30Kcal/kg 35Kcal/kg

Normal 30Kcal/kg 35Kcal/kg 40Kcal/kg

Under weight 30Kcal/kg 40Kcal/kg 45-50Kcal/kg

METHOD 4 (For Paeds use the following Ranges):

Age Kcals/ kg
Up to 1 year 80 kcal/kg
12 ‐ 18 months 75 kcal/kg
18 months ‐ 3 years 70 kcal/kg
4 ‐ 6 years 65 kcal/kg
7 ‐ 8 years 60 kcal/kg
9 ‐ 10 years 55 kcal/kg
11 ‐ 14 years 40 kcal/kg or less

METHOD 5 (For Paeds use the following formulas)

0-3 years old:

• Males: (60.9 x Wt) -54
• Females: (61 x Wt) -51

3-10 years Toddlers:

• Males: (22.7 x Wt) -495
• Females: (22.4 x Wt) -499

10-18 Years Children:

• Males: (12.2 x Wt) -746
• Females: (17.5 x Wt) -651

2. Estimating Protein Needs:

Health State Protein in g/kgBW
Normal Health 0.8-1.0gm/kg body wt.
Fever, Fracture, Infection 1.5-2gm/kg body wt.
Protein Depleted 1.8-2gm/kg body wt.
Extensive Burns 1.5-3.0gm/kg body wt.

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 *For certain health conditions use the grams of protein mentioned in the MNT

3. Estimating Fluid Needs:

METHOD 1 (Based on Age):

Age ml/kg Body Weight

0-5 months 120-150
5 months – 1 yr. 125 – 145
1-3 yr. 114 – 115
4-6 90-110
7-10 70-85
11 70–85
Children (In general) 70-110
Adolescent 40-60
Adult 30-50

METHOD 2 (Based on Weight):

First 20 kg 1500 ml and for each additional kg 25ml

METHOD 3 (Based on Energy Intake):

1ml/ Kcal

***Fluid Calculation for Renal Patients In oliguria restricted to the daily urine output plus 500
ml. this includes the water present in foods and drink.

4. Types of Activity, Activity Factors and Injury Factors:

Types of Activity:

Sedentary Activity: Eating, Writing, Watching television, working on computer, typing and table
work in office.

Light Activity: Preparation of food, washing the utensils, dusting, ironing, light walk, fast computer
typing.

Moderate Activity: Mopping, booming and brisk walk.

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Vigorous Exercise: Washing clothes with hands, white washing, and very brisk walk, playing golf
and gardening.

Strenuous Exercise: Swimming, jogging, bicycling, playing cricket and other games.

Activity Type Factor

No Activity 1.0-1.1
Slightly Active 1.2-1.3
Moderate Active 1.3-1.5
Athletes Heavy 1.5-1.7

Injury Factor:

Injury Type Range

Minor 1.0-1.1
Surgery
Major 1.3-1.5
Mild 1.0-1.2
Infection Moderate 1.2-1.5
Severe 1.4-1.8
Skeletal 1.2-1.35
Trauma
Blunt 1.15-1.35
Upto 40% Body Surface Area 1.0-1.5
Burns
100 % BSA 1.95

Recommendations for Infants and Children Under 2 Years:

Age Instructions

4 – 6 months Breast feed on demand at least 8 times a day

Around 6 months Start supplementary foods
Around 6 – 12 Breast feed as often as child wants give supplementary foods 3-4
months times.
Breast feed as often as child want. Give supplementary foods 4 – 5
12 – 23 months
times.
Over 2 years Feed 3 meals and 2 snacks / day.

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Food Group Guide for 2-6 Years Olds:

Food Groups Servings

Milk and milk products: 2-3 servings
Meat and substitutes: 2-3 servings
Vegetables: 3 servings
Fruits: 2 servings
Bread and cereal: 6 servings
Fat and oils: 3-4 servings

My Plate:

My Plate is a reminder to find your healthy eating style and build it throughout your lifetime.
Everything you eat and drink matters. The right mix can help you be healthier now and in the future.

This means:
• Focus on Variety, Amount, and Nutrition.
• Choose foods and beverages with less saturated fat, sodium, and added sugars.

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 • Start with small changes to build healthier eating styles.
• Support healthy eating for everyone.
• Eating healthy is a journey shaped by many factors, including our stage of life, situations,
preferences, access to food, culture, traditions, and the personal decisions we make over time.
All your food and beverage choices count. My Plate offers ideas and tips to help you create a
healthier eating style that meets your individual needs and improves your health.
• Build a Healthy Eating Style
• All food and beverage choices matter focus on variety, amount, and nutrition
• Focus on making healthy food and beverage choices from all five food groups including
fruits, vegetables, grains, protein foods, and dairy to get the nutrients you need.
• Eat the right amount of calories for you based on your age, sex, height, weight, and physical
activity level.
• Building a healthier eating style can help you avoid overweight and obesity and reduce your
risk of diseases such as heart disease, diabetes, and cancer.
• Choose an eating style low in saturated fat, sodium, and added sugars.
• Use Nutrition Facts labels and ingredient lists to find amounts of saturated fat, sodium, and
added sugars in the foods and beverages you choose.
• Look for food and drink choices that are lower in saturated fat, sodium, and added sugar.
• Eating fewer calories from foods high in saturated fat and added sugars can help you manage
your calories and prevent overweight and obesity. Most of us eat too many foods that are
high in saturated fat and added sugar.
• Eating foods with less sodium can reduce your risk of high blood pressure.

Make Small Changes to Create a Healthier Eating Style:

Think of each change as a personal win on your path to living healthier. Each My Win is a change
you make to build your healthy eating style. Find little victories that fit into your lifestyle and
celebrate as a My Win!

• Start with a few of these small changes.

• Make half your plate fruits and vegetables.
• Focus on whole fruits.
• Vary your veggies.
• Make half your grains whole grains.
• Move to low-fat and fat-free dairy.
• Vary your protein routine.
• Eat and drink the right amount for you.

Support healthy eating for everyone

• Create settings where healthy choices are available and affordable to you and others in your
community.

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 • Professionals, policymakers, partners, industry, families, and individuals can help others in
their journey to make healthy eating a part of their lives.

Dietary Guidelines 2015-2020 (USDA)

The Guidelines:

Follow a healthy eating pattern across the lifespan. All food and beverage choices matter. Choose a
healthy eating pattern at an appropriate calorie level to help achieve and maintain a healthy body
weight, support nutrient adequacy, and reduce the risk of chronic disease.

Focus on variety, nutrient density, and amount. To meet nutrient needs within calorie limits, choose a
variety of nutrient-dense foods across and within all food groups in recommended amounts.

Limit calories from added sugars and saturated fats and reduce sodium intake. Consume an eating
pattern low in added sugars, saturated fats, and sodium. Cut back on foods and beverages higher in
these components to amounts that fit within healthy eating patterns.

Shift to healthier food and beverage choices. Choose nutrient-dense foods and beverages across and
within all food groups in place of less healthy choices. Consider cultural and personal preferences to
make these shifts easier to accomplish and maintain.

Support healthy eating patterns for all. Everyone has a role in helping to create and support healthy
eating patterns in multiple settings nationwide, from home to school to work to communities.

Key Recommendations:

The Dietary Guidelines Key Recommendations for healthy eating patterns should be applied in their
entirety, given the interconnected relationship that each dietary component can have with others.

(Consume a healthy eating pattern that accounts for all foods and beverages within an appropriate
calorie level) A healthy eating pattern includes:

• A variety of vegetables from all of the subgroups—dark green, red and orange, legumes
(beans and peas), starchy, and other
• Fruits, especially whole fruits
• Grains, at least half of which are whole grains
• Fat-free or low-fat dairy, including milk, yogurt, cheese, and /or fortified soy beverages.
• A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans
and peas), and nuts, seeds, and soy products.
• Oils

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A Healthy Eating Pattern Limits:

Saturated Fats and Trans Fats, added Sugars, and Sodium:

Key Recommendations that are quantitative are provided for several components of the diet that
should be limited. These components are of particular public health concern in the United States, and
the specified limits can help individuals achieve healthy eating patterns within calorie limits:

• Consume less than 10 % of calories per day from added sugars

• Consume less than 10 % of calories per day from saturated fats
• Consume less than 2,300 milligrams (mg) per day of sodium

If alcohol is consumed, it should be consumed in moderation up to one drink per day for women and
up to two drinks per day for men and only by adults of legal drinking age.

In tandem with the recommendations above, Americans of all ages children, adolescents, adults, and
older adults should meet the Physical Activity Guidelines for Americans to help promote health and
reduce the risk of chronic disease. Americans should aim to achieve and maintain a healthy body
weight. The relationship between diet and physical activity contributes to calorie balance and
managing body weight. As such, the Dietary Guidelines includes a Key Recommendation to meet the
Physical Activity Guidelines for Americans.

Estimated Recommendations for Calories:

Total Calories Per Day:

Gender Underweight Normal Overweight/ Obese

Males 2200-2400 1600-1800 1200-1400
Females 1800-2000 1400-1600 1000-1200

Servings Sizes According to Calories:

Food Groups 1000 1200 1400 1600 1800 2000

Milk 1 2 2 3 4 4
Fruits 2 3 3 3 3 3
Vegetables 2 2 3 3 3 3
Breads and 4 4 5 6 8 10
Cereals
Meat 3 3 4 4 5 5
Fat 2 2 3 3 3 4

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 EXCHANGES
CHO (g)
Pro (g)
Fat (g)

Serving Sizes of Food Groups:

Food Groups Serving Sizes

Milk and Milk Products 1 exchange = 1 c or 8 Oz milk or ¾ C yogurt

Meat and Meat 1 exchange = 1 Egg, 2 Whites, 1 Oz Meat (1 inch cube) or 2

Substitutes tbsp. of cheese
1 exchange = 1 Slice White Bread/ 2 slice Bran Bread, 1 (6’’)
Bread or Cereal
chapatti or ½ cup of cereal, pasta or starchy vegetables

Vegetables 1 exchange = ½ cup cooked vegetables or 1 cup raw

1 exchange = 1 small fruit, ½ C fruit juice or 3 oz. grapes or

Fruits
2-3 plums
1 exchange = 1 tsp oil/ghee/ butter, 7-8 Peanuts, 2 walnuts,
Fats
5-6 cashews or 4-5 olives

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 Eating Plan Pattern

Serving size/
Timing Food Item CHO Protein Fat Other Kcal
Amount
………………. ……………….
Pre
………………. ………………. …… …… …… …… ……
Breakfast
………………. ……………….
……………….
………………. ……………….
Breakfast ………………. ………………. …… …… …… …… ……
………………. ……………….
……………….
………………. ……………….
Snack ………………. ………………. …… …… …… …… ……
………………. ……………….
……………….
……………….
……………….
……………….
Lunch ………………. …… …… …… …… ……
……………….
……………….
……………….
……………….
………………. ……………….
Snack ………………. ………………. …… …… …… …… ……
………………. ……………….
……………….
……………….
……………….
……………….
Dinner ………………. …… …… …… …… ……
……………….
……………….
……………….
……………….
………………. ……………….
Snack ………………. ………………. …… …… …… …… ……
………………. ……………….
TOTAL …… …… …… …… ……

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 ASSIGNEMNTS

1. Highlight the common food items consumed in Pakistan.

2. Make a Diet Plan for yourself on form A.
3. Perform assessment of a child and plot the chart for IBW, Over and Underweight.

(For growth charts for boys and girls turn to next page)

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