Nutritional Assessment

What is Nutritional
Assessment?
“the evaluation of nutrition needs of individuals
based upon appropriate biochemical,
anthropometric, physical, and dietary data to
determine nutrient needs and recommended
appropriate nutrition intake including enteral
and parenteral nutrition”
- American Dietetic Association
Nutritional Assessment & Clinical
Application - Overall View
Nutrition Management:
• Assessment
• Intervention
• Follow-up / Review
• Evaluation

Consider:
• Health care setting
• Disease / condition
• Lifecycle / physiological state
 Nutritional Status
• “Nutritional Status expresses the degree to which
physiologic needs for nutrients are met”
• Optimal NS = Balance between intake and requirement
• Malnutrition
– state caused by nutritional deficiency
– Reversible by providing appropriate nutrition support
• Deficiency vs Overload
(can be combination of both)
• “whole person” focus, not just disease or condition
focus.
 Nutritional Risk
• Critically unwell patients may be well
nourished but high nutritional risk

• Illness, injury, infection

 Metabolic derangements
 May have significant affect on nutritional status
 May lead to malnutrition
 Cannot be corrected by nutrition support alone

• Patients at high nutritional risk will require

early nutritional intervention and close
monitoring
 Why do we need to
identify malnutrition?

• Malnutrition is associated with:

  length of stay in hospital
  complications
  hospital costs
  mortality rates
Screening vs Assessment
 Nutrition Screening Tools
• Requirements
– quick and simple to administer
– sensitive enough to identify individuals at risk
– appropriate for client group being screened
– capable of being used by non-dietitians
– reproducible when used by different
observers
– able to guide non dietetic staff into taking
appropriate action for findings recorded
Malnutrition Screening Tool (MST)

Have you lost weight recently without trying?

If NO 0
If unsure 2
If YES, how much weight have you lost?
1 – 5 kg (2 – 11 lb) 1
6 – 10 kg (1 – 1½ st) 2
11 – 15 kg (1¾ - 2⅓ st) 3
> 15 kg (> 2⅓ st) 4
Unsure 2
Have you been eating poorly because of a
decreased appetite?
If NO 0
If YES 1
Total

If the score is 2 or more please refer to the

dietitian.
 The Short Nutritional
Assessment Questionnaire
(SNAQ)
Question
Score

Did you lose weight unintentionally?

>6kg in the past 6 month 3

>3kg in the past month 2
Did you experience a decreased appetite
over the past month?
1
Did you use supplemental drinks or tube
feeding over the past month?
1
 Nutritional Assessment Tools
• No single / standard way of assessing nutritional
status

• Various validated assessment tools developed

– some disease specific
– some age specific

• 2 examples
– Mini Nutritional Assessment (MNA)
– Subjective Global Assessment (SGA)
Mini Nutritional Assessment
(MNA)
• Screening and Assessment tool for the
identification of malnutrition in the
elderly
• Considers:
– Dietary Intake – foods, patterns
– Weight change, BMI, Muscle circumferences
– Functional impairment, Independence,
Living arrangements
– Psychological issues, Self assessment
 Subjective Global
Assessment
• Valid assessment tool

• Strong correlation with other subjective

and objective measures of nutrition

• Highly predictive of nutritional status in a

number of different patient groups

• Quick, simple and reliable

 Subjective Global
Assessment…features
• Medical History
– Weight change
– Dietary intake
– GI symptoms
– Functional impairment
• Physical Examination
– Loss of subcutaneous fat
– Muscle wasting
– Oedema and ascites
Subjective Global Assessment
…Classifications

A Well nourished

B Moderately malnourished or
suspected of malnutrition

C Severely malnourished
 Full Nutrition Assessment
Step 1…Data collection
• Systematic Approach
• Assessment based on
clinical/psychosocial/physical information
– Dietary
– Anthropometric
– Biochemical
– Physical
• Including
– Subjective (eg. signs/symptoms of nutritional
problem, appetite)
– Objective (eg. Lab results)
 Data Collection…
An Example… A B C D E
A Anthropometry
B Biochemical Data
C Clinical signs and symptoms, medical
condition
D Dietary Intake
E Exercise (Energy balance –
expenditure)

Consider current level, history and changes

 Anthropometry

• Height • MAMC
• Weight • TSF
• Weight history /
pattern • Waist circumference
(% weight change) • Hip circumference
• Weight for Height • WHR
• BMI
• Growth Pattern, head
circumference Be aware of fluid
(paediatrics) status, presence of
oedema.
 Anthropometry – Body
Composition

Muscle, Fat, Bone, Water

Body Mass: Fat Store:
• LBM – Body mass • Essential Fat for
that contains small physiological
% (~3%) essential function, eg. fat
fat stored in muscle,
[Essential fat + liver, heart
Muscle + Water + • Storage fat in
Bone] adipose tissue –
• Fat Free Mass (FFM) visceral fat and
subcutaneous fat
 Body Compostion cont’d.
• Practical Methods in Clinical Setting:
– Weight, height & weight Hx
– Skinfolds, circumferences
• TSF, MAMC,WHR
• More precise, occasional use:
– Bioelectrical Impedance Analysis (BIA)
• FFM, % body fat
– Dynamometry (grip strength)
• Precise, Expensive, Research purposes:
– CT, MRI, Dexascan, TBK,TBN
Biochemistry & other Blood Tests
(See also disease/condition specific lectures)

• Objective measures
• No single test is diagnostic
• Consider “normal / recommended range” for
various and combination of conditions, eg.
age, gender, physiological state, disease type
and stage
• Consider clinical significance of test result
• Test result may reflect immediate intake (eg
glucose) or long term status (HbA1c)
 Other factors to Consider…

• Other factors can mask/influence

test results eg.
– Acute phase response due to stress /
injury ( reduced albumin)
– GI bleed (higher urea)
– blood transfusion (higher serum K
and Hb)
– Surgery (lower Hb and albumin)
 Nutritional Indicators
• Ideal indicator or marker is sensitive
and specific to nutritional intake

Commonly Used “Nutritional Indicators”

– Albumin
– Pre-albumin
– Transferrin
– Retinol-binding protein
Biochemistry & other Blood Tests,
cont’d
(See also disease/condition specific lectures)

• Interference – drugs, sampling

• Nutrient-nutrient interactions, drug-
nutrient interactions
• Be aware of hydration status
• Must interpret lab results with other
nutritional parameters
Clinical issues to consider:
• Medical history, treatment and
medications
• Significant factors affecting nutritional
intake
• Fluid balance – input and output, Bowel
habits
• Physical assessment of nutritional
status
• Clinical signs and symptoms
Clinical Signs and Symptoms
Signs Symptoms
• Subjective, • Recall, report by
impression subjects
• Descriptive,
observation • Descriptive
• Appearance • Eg nausea, itchiness,
• Visual examination diarrhoea, anorexia
• Needs clinical
judgement
• Eg muscle wasting,
malnutrition
 Dietary Intake

(See relevant lectures in dietary intake, RDIs, etc)

• Is intake meeting requirement?

– Basic nutrition adequacy
– Special requirement / disease / conditions
• Consider factors affecting intake
• Consider clinical, nutritional and psycho-
social issues
• Methods of collecting information/data
• ?Relevant and practical
Exercise – Energy Balance
• Nutrition and exercise closely linked – metabolic and
physical fitness
• Functional capacity and Nutritional status
– Correlation between muscle mass and physical strength,
nutritional status and physical function
• Energy Balance to attain optimal weight and body
composition
• Bed Rest / Inactivity
– Negative effects on muscles, bone and CV system, eg. 8 g
protein loss / day of bed rest
– Exercise – affects on appetite, bowel function
 Estimating Nutritional
requirements

Consider
•Energy
•Protein
•Fluid
•RDIs for micronutrients
 Estimating Energy
Requirements
• Indirect Calorimetry
– preferred method
– use of a metabolic monitor/cart
– measures respiratory gas exchanges
– Differences in oxygen and carbon dioxide content between
air going in and air coming out  respiratory exchange 
energy expenditure

(Ref: Mann & Truswell(ed) Essentials of Human Nutrition, Chap. 5)

 Fluid Requirements
Different methods used:
• 35 – 45 mL/kg body weight
– 30mL for older adults
– 40 – 45 mL for active young adult
• 0.24mL/kJ energy given
• 1500mL + add 20mL per
additional kg over 20kg