Clinical Nutrition Quiz 1

What are the 4 pieces of nutritional assessment?

Anthropometrics, Biomarkers, Clinical, Diet

What is included in anthropometrics?

Weight, BMI, waist to heigh ratio, waist circumference, waist to hip ratio, BP

Name this BMI Category: <16.0

Severe thinness

Name this BMI Category: 16.0 - 16.9

Moderate thinness

Name this BMI Category: 17.0 - 18.49

Mild thinness

Name this BMI Category: 18.5 - 24.9

Normal range

Name this BMI Category: 25 - 29.9

Preobese

Name this BMI Category: 30-34.9

Obese class 1

Name this BMI Category: 35.0 - 39.9

Obese class 2

Name this BMI Category: > or equal to 40

Obese class 3

What are better measurements of body weight and health risk?

% weight change = (weight change/ pervious weight) *100

Waist Circumference Healthy vs Unhealthy

Men: < or equal to 40 inches vs > 40 inches

Women: < or equal to 35 inches vs > 35 inches

Waist to hip ratio healthy vs unhealthy

Men: < or equal to 0.95 vs >0.95

Women: < or equal to 0.80 vs >0.80

Waist to height ratio healthy vs unhealthy

< 0.5 vs > 0.5

What is Normal BP?

< 120 systolic AND < 80 diastolic

What is elevated or pre hypertensive BP?

120 -129 systolic AND < 80 diastolic

What is Hypertension, Stage 1?

130 - 139 or 80 - 89 diastolic

What is Hypertension Stage 2?

greater than or equal to 140 systolic or > or equal to 90

How do we estimate healthy protein requirements?

• Minimum for healthy (sedentary) patients: 0.8 g/kg bw

• > 2 g/kg bw if BMI is 30-40

• > 2.5 g/kg if BMI is >40

• 1.25 - 1.5 g/kg bw for pressure ulcers

Practice this calculation example:

Healthy male, weighs 195lbs, sedentary

1. Take weight in pounds, divide by 2.2 to convert to kg

2. Multiply weight in kg by protein conversion factor

3. Round to nearest whole number

1. 195 / 2.2 = 88.64kg

2. 88.64kg * 0.8 g/kg bw = 70.91 g

3. 71 g

What is a static assay used in biochemical analysis?

Measures the concentration of a specific nutrient in a biological sample (ex. Vit K levels)

What is a functional assay used in biochemical analysis?

Assess the biological activity or function related to that nutrient ( evaluating clotting time)

Other types of nutritional biomarkers: Exposure

Short term vs long term

carotenoid intake for fruits and veggies

Other types of nutritional biomarkers: Effect

Response of the body to a specific exposure

Risk effect biomarkers like fasting plasma glucose or lipoprotein ratios, C reactive protein as a functional marker for inflammation

Other types of nutritional biomarkers: Susceptibility

Indicator of status for host factors, accumulating compounds, etc.

Ferratin as susceptibility for iron stores, cobalamin for B12, glutathione peroxidase for selenium status

What are some issues with biochemical analysis?

May be influenced by non-nutritional factors, Some test are non specific, FDA does not regulate lab tests for validity or clinical efficacy

*There is not a single test or group of tests that are sufficient for monitoring nutritional status*,

What is the effect of inflammation and biomarkers on biochemical analysis?

Inflammation can significantly affect biomarker levels, leading to misinterpretation of nutritional status.

An example of inflammation and biomarkers on biochemical analysis

Elevated CPR indicates inflammation, which can mask underlying nutritional deficiencies like iron deficiency anemia.

What criteria must biomarkers follow?

• Determined by solid, sensitive, reproducible methods which should be highly specific & economically feasible

• Concentration in the sample must be sensitive enough to show changes in relation to health status & dietary intervention, & they have to be specific for their intended purpose

What are stool tests used to analyze?

Analyze fatty malabsorption, fatty malabsorption, certain pancreatic issues, & GI flora & related issues, blood, pathogens

Those with chronic GI issues might benefit from having GI flora tested, but make sure labs does high throughout 16S RNA or DNA analysis for anerobic bacteria

Why are fecal occult blood tests ordered?

Unexplained anemia

What is Fecal elastase- 1?

Great marker for pancreatic function

What are the most common specimen types?

Whole blood, serum, plasma, blood cells, erythrocytes, leukocytes, blood spots, urine, breast milk, extracellular vesicles

What can blood cells tell?

a 120 day window into intracellular & membrane composition

What can extracellular vesicles tell?

information about specific tissues that may not be accessible like CNS

Specimen Types: Breath

evaluate sugar (lactose or fructose) malabsorption

Specimen Types: Hair and Nails

DNA testing, heavy metals, ilicit drugs

Specimen Types: Saliva

May be used for some hormone levels

Specimen Types: Sweat

Electrolyte test (Cl-) for cystic fibrosis

Assessment of hydration status by:

Serum Na +, BUN, serum osmolality, urine specific gravity

How to test intestinal permeability

Lactulose mannitol urine test, measurement of sugars that past through intestinal lining

Determining the results of a lactulose mannitol urine test

Normal with elevated Lactulose/Mannitol ratio: Increased permeability

Low mannitol with normal/elevated ratio: Malabsorption

What are the promising biomarkers of oxidative stress?

Malondialdehyde (MDA), nitrotryrosine, myeloperoxidase (MPO), oxidized LDL

Highlights from Lab Assay tables: Vit D

Lowest in spring, highest in summer, measure calciferol (25-hydroxyvitamin D3/ inactive form) ← static biomarker

Highlights from Lab Assay tables: B12

MMA (methylmalonic acid) is best indicator

Highlights from Lab Assay tables: IV MG & 24- hour urine excretion

Gold standard for measuring Mg

Pts at risk for Mg deficiency → 2 major risk factors or 1 major and 2+ minor risk factors

Highlights from Lab Assay tables: Copper

Ceruloplasmin is the best indicator

Assay table Note

Ferritin, iron, transferrin & % transferrin saturation all evaluated together as part of iron panel

Major and minor health risk factors: Disease

Major: Diabetes, heart disease

Minor: Osteoporosis

Major and minor health risk factors: Diet

Major: Soda, processed foods

Minor: Coffee, alcohol, protein

Major and minor health risk factors: Medication

Major: Diuretics, antacids

Minor: Oral contraceptives, antibiotics

Major and minor health risk factors: Clinical History

Major: Leg cramps

Minor: Sleep disorders, fibromyalgia, chronic fatigue syndrome

Major and minor health risk factors: Metabolic Status

Major: Metabolic syndrome

Minor: BMI >30 kg/m2

What are some measures positive acute phase reactants of inflammation? (Increased on Labs)

High sensitivity CRP (MC)

Fibrinogen, ferritin, ceruloplasmin

Alpha-1 antitrypsin, alpha-1 antichymotrypsin, haptoglobins

What are some measures negative acute phase reactants of inflammation? (Decrease on Labs)

Albumin, transferrin

Prealbumin (transthyrentin), retinol-binding protein

Albumin provides about 80% of osmotic pressure so we could get some leaking of fluid into interstitial spaces, it also has fairly long half-life (18-21 days) so we can’t reassess it quickly

Macrocytic Anemia overview:

RBC size >99 fl (MCP/ mean corpuscular volume is large)

Folate or B12 deficiency

Macrocytic Anemia Assessment:

Folate→ RBC folate is a better marker

B12 → measured in serum (static)

*B12 & methylmalonic acid → MMA in urine is used to differentiate between B12 & folate def (best biomarker for B12 def)

Serum homocysteine→ surrogate measure of folate or B12 status could be due to diet or genetic defect

Microcytic anemia overview:

RBC size <80 fl (MCP is small)

Most likely iron deficiency, could also be copper

Microcytic anemia assessment:

Hematocrit → % of RBC in total blood volume

Hemoglobin → total Hgb in RBC

*Ferritin → Iron storage in liver (best overall marker of iron)

Serum iron → binding capacity (TIBC) → measure of all proteins able to bind mobile iron

Transferrin saturation → measure of iron availability to tissues

Can a micronutrient panel be orderd?

No

Nutritional cause of poor wound healing

Protein, Vit C, or zinc def

Nutritional cause of follicular hyperkeratosis

Vit A or C def

Nutritional cause of dermatitis

Niacin or tryptophan def

Nutritional cause of pallor

Iron, B12, B6, copper, zinc, or folate def

Nutritional cause of petechiae

Vit K or C def

Nutritional cause of ecchymoses

Vit C def

Nutritional cause of spooning nails (koilonychia)

Iron, protein def (late stage iron)

Nutritional cause of dull nails

iron, zinc, protein, biotin, B12

Nutritional cause of transverse lines in nails (beau’s lines)

Severe zinc def, protein def (MC)

Nutritional cause of mottled nails

zinc, iron, Vit B12

Nutritional cause of thin easily pluckable hair

protein def, malnutrition, essential FA def

Nutritional cause of moon face

protein def

Nutritional cause of pale conjunctiva

iron (MC), copper, B6, B12, folate def

Nutritional cause of bitot’s spots

Vit A def

Nutritional cause of keratomalacia

Vit A def

Nutritional cause of angular palpebritis (redness in corner of eyes)

Niacin, riboflavin, iron, B6 def

Nutritional cause of angular stomatitis (mouth & lips)

Riboflavin, niacin, B6, iron, B12 def

Nutritional cause of cheilosis

Riboflavin, niacin, B6, iron, B12 def

Nutritional cause of magenta tongue

Riboflavin def

Nutritional cause of glossitis

Riboflavin, niacin, B6, B12, folate, iron def

Nutritional cause of dysgeusia

zinc def

Nutritional cause of receding gums

Vit C (MC) or riboflavin def

Nutritional cause of calf or thigh pain

thiamin def

Nutritional cause of dementia

Niacin, B12 def, calcium or aluminum toxicity

Nutritional cause of tetany

Calcium (MC), magnesium, zinc, Vit D def, sodium or phosphorus excess

What food related history should be gathered from a patient?

Food & nutrient intake, meds & supplements, Knowledge/beliefs/attitudes, behavior, access to food and diet history.

What is included in diet history?

foods avoided due to allergies, appetite, dietary modifications due to chronic disease, educational background, GI issues, person in household who grocery shops or cooks, perceived concerns of the patient, physical activity

24- hour recall pros and cons

Pro: Quick & easy, relies on short term memory

Cons: Inability of patients to remember portion sizes, may not represent usual intake, requires good interview skills

Food diary (3-7 days) pros and cons

Pros: provides daily info & with more detail (how prepared, timing, ect)

Cons: Depends on literacy skills of pt, requires knowledge of portion sizes, high response burden on patients, may alter diet to make record keeping easier

Food Frequency Questionnaire pros and cons

Pros: Standard & gives overall picture of intake

Cons: Depends on literacy skills of pt, requires knowledge of portion sizes, difficult to extrapolate to other populations

What is the Nonquantitative FFQ?

Assesses frequency of food consumption without use of portion sizes

What is the Semiquantitative FFQ?

Assesses frequency of food consumption using predefined portion sizes

What is the Quantitative FFQ?

Assesses frequency of food consumption and asks patients to record their usual portion sizes, sometimes defined as small, medium, or large

What is the MUST and PG-SGA tools used to screen for?

Malnutrition universal screening tool screen adults at risk for malnutrition.

Important for cancer survivors or those with eating disorders

What does MUST and PG-SGA assess?

BMI, weight loss, & acute disease effect, if they score 2+ → refer out to registered dietitian

What is the MEDFICTS?

questionnaire focusing on fat & cholesterol intake

What is REAP?

Rapid Eating Assessment for Patients

What is WAVE?

Weight, Activity, Variety, Excess

Functional Nutritional Approach: Ingestion

Food, fiber, water, supplements, meds

Intake patterns affected by emotional disorders

Toxins entering body via food, skin, inhalants, water, environment

Functional Nutritional Approach: Digestion

Adequate microflora, Allergies, genetic enzyme deficiency, hydration status, Inflammatory status, Lifestyle (sleep, exercise, stress)