Preventive (D1 Spring) Exam Two [Nutritional Assessment: Marshall]

You need to acknowledge the _____ health in order to be an effective dentist

nutritional

note

- or any conditions

Nutritional care can be divided into 4 areas

Assessment

Planning

Implementation (education)

Evaluation

Assessment

Identification if there is a problem and what is the problem

Planning

Determine the best method of treatment

Consider compliance and resources

Implementation

Putting the plan into action. Includes education of the patient

May never occur depends on the patients perspective of the problem

Evaluation

Review the plan assess the situation. Is it still appropriate. Modify and reinforce

Levels of nutritional assessment

Screening assessment

- most basic really identify who needs additional assessment.

Primary assessment

- Routinely conducted at WIC or public health clinic with basic treatment or referral. What you do for patients who fail their screen and or have obvious oral disease

Secondary assessment

- Generally at hospital level, with a dietitian, secondary level of care

Tertiary assessment

- At a specialty center for patients with significant needs. For example patient with eating disorders at an ED clinic

Nutritional assessment: Definition

Definition: Evaluation of a person's health from a nutritional perspective

Nutritional assessment: Objective

Objective: To identify individuals who are malnourished or at "risk" for malnutrition

Malnutrition is due to

Deficiency of nutrients/energy

Excess of nutrients/energy

Imbalance of nutrients

Clinical classification of malnutrition

Over: Physically obvious, visible

Subclinical: Before clinical signs or symptoms are apparent

Causes of Deficiencies (toxicity)

Primary: Due to inadequate dietary intake

- primary toxicity is due to excessive intake

Secondary: Due to altered 'other', adequate dietary intake

- secondary toxicity is associated with decreased need, utilization, excretion

Can't pick up a secondary concern with a diet screening because they could have adequate diet

Components of nutritional assessment

Histories- gathering subjective/objective information.. helps to establish rapport as well as identify patient's perspective of health/diet what they might be willing to change.

Anthropometric measures- Measuring the body

Clinical appearance- what do you see when you look at the patient

Biochemical measures- Lab values

Histories: Medical history

Assessment of high risk conditions that predispose or accompany malnutrition

- diagnosis

- infection history

- surgical history

- family history

- mental health status

- growth

Histories: Socioeconomic history

Assessment of social/environmental factors affecting ability to obtain proper nutrition

- Finances

- Physical facilities

- Social support

- Community resources

- Education

Histories: Medication history

Assessment of food or nutrient-medication interactions

- nutrition supplements

- over-the-counter medications

- prescription medications

- street drugs

Histories: Dietary history

Assessment of intake and factors which influence intake

- Current intake- past intake

- Dietary habits

- Feeding skills development

- Psychosocial factors

- Prescribed/self-imposed diets

- activity patterns

- family/culture/environment

How do we asses current intake

24 hour/usual recall

Food records

Food frequencies

Observation

Questionnaires

24 hour/usual recall

List what ate yesterday...usually

1. memory dependent-but easy

2. Good for groups; need 3-21 recalls for accurate nutrient intake by an individual

Food records

3-7 days; > 3 loose compliance

1. record as eat- accurate; burdensome

2. Change eating with recording?

3. Increase awareness of usual habits

Food frequencies

questionnaires that assess frequency and/or quantity of foods contributing key nutrients/energy

1. Specific to population

Observations

Ideal but artificial

Questionnaires

Use with above to gather additional information

Not always feasible to assess current intake:

Patient with alcohol issues

history of traumatic brain injury as child

Intake evaluation

Food group analysis

- myplate

Nutrient analysis

Energy analysis

Anthropometric measures

Measurement of body size, weight or proportions

Indirect assessment of body composition

Weight = Fat mass + Fat-free mass

Reference populations

Anthropometric: basic components

Height

- generally think of standing height

Weight

Circumferences:

- head

- midarm

- waist

- hip

Skinfolds:

- triceps

- subscapular

- suprailiac

Anthropometric applications

Growth and development

- standards

Nutritional status

- change

Body composition

- body mass index

Body fat distribution

- waist to hip ratio

- Waist circumference

BMI + Waist circumference

- Disease risk

Disease risk: BMI x Waist circumference

Obesity Definitions- BMI-based definition of obesity

Obesity Definitions- preclinical vs clinical

Clinical Appearance

Signs and symptoms

Overt (visible) signs of malnutrition

- hair

- skin

- eyes

- oral tissue - tongue gums teeth lips

- nails

- muscles, skeletal system

Biochemical measures

Measurements of a nutrient or metabolite in blood urine or body tissue

Measures may be static or functional

Useful to detect subclinical and confirm clinical malnutrition

Problem

- nonspecific

- values influenced by nonnutritional factors such as disease, trauma, medications

Biochemical measures: Protein status

Visceral--serum albumin, prealbumin, transferrin

Somatic-- creatinine excretion, creatinine height index, 3-methylhistidine

Biochemical measures: Iron status

Serum ferritin, transferrin saturation, hemoglobin, mean corpuscular volume

Biochemical measures: Vitamin A status

Serum Vitamin A, dark adaptation, liver stores

Summary nutritional assessments

History --brief

- 24 hour/usual recall

Anthropometric

- weight, height

Clinical appearance --obvious

Biochemical measures

- screen specific (hematocrit, cholesterol)

Conclusion

Age determines focus assessment

- children- expect growth and development

- adult- expect maintenance of weight and height

Change is significant for individuals

Combination of tools

- no one tool is ideal

Treatment vs preventions

- cheaper higher cost effectiveness

- Less morbidity and morality

Go through case studies: NOT on slide video ~1:03:06

How do they want us to apply the nutritional assessment to dental clinic

Consider medical history, drug history, anthropometrics, and clinical appearance with diet to consider implications for oral health

DIETARY ASSESSMENT OF PATIENTS

DIETARY ASSESSMENT OF PATIENTS

Practical assessment strategies

Screen: every patient

Assess: Those identified at caries risk or with other oral health red flags

- obvious disease- target assessment towards current disease

- healthy- target assessment towards prevention

Refer: Patients with dietary/systemic health red flags

Goals of screening process

Identify patients at risk due to marginal dietary habits

- caries risk

- periodontal disease risk

- systemic health risk

Screening process- caries

Dietary factors (worksheet)

Frequency

- eats more than 3 meals per day

- eats more than 3 snacks per day

- meals/snacks are not structured

Drinks sugared beverages (juice, soft drink, etc)

- drinks more than 20 oz sugared beverage daily

- drinks beverages for more than 30 minutes daily

Eats sugared candy or medicated lozenges daily

If nothing else what should be your three questions for screening

1. Unstructured meals

2. Daily sugared beverages

3. >30 minutes

Screening process- general

Compliance with MyPlate

- all food groups in adequate quantities

- all food groups consumed daily; inadequate quantities

- missing food groups

Unintentional weight loss or gain

- defined as weight change or more than 10 pounds in 6 months

- consider medical referral- not natural

Food security

Defined as access to enough food at all times for an active healthy lifestyle

- availability

- accessibility

- utilization

- stability

Food insecurity

Defined as limited or uncertain access to adequate food due to economic or social conditions

- high food security (food security)

- Marginal food security (food security)

- Low food security (food insecurity without hunger)

- Very low food security (food insecurity with hunger)

Clinical form

Goals of assessment strategy

Identify dietary habits that increase disease risk

- educate as to rationale for 'better' dietary habits

- provide guidelines to achieve 'better' dietary habits

- focus recommendations

-- patient motivation

-- Reasonable changes

Practical perspective

- easy for clinician

- efficient for practice

- patient has to remember conversation when they get home

Chairside diet assessment of caries risk: Best practices

Defines key dietary areas for caries risk

Presents concept of anticipatory guidance

- recognize obstacles and provide advice before obstacle becomes problem

- no one food is consumed in isolation

-- what are ripple effects of consumption

-- what are ripple effects of lack of consumption

Examples

Foundation for brochure development

Brochure: Objectives

Facilitate patient education regarding dietary risk factors for caries

streamline caries risk assessment for patients identified at risk

Facilitate dietary recommendations targeting undesirable habits

Enables anticipatory guidance with respect to remainder of diet

Take home tool so patients remember conservation

Brochure: Components

Caries risk factor

- education

MyCavity Risk

- identify patient risk factor

- provide recommendations

MyPlate

- emphasize dietary foundation

- provide guidelines as to what should be eating

Additional recommendations

- reinforcement and extra guidelines

Fitting the pieces

- education

Brochure: general

Conversation with patient

- dietary change occur over time

- Document conversation and evolution of habits

Axium... screen shot

- forms

- caries risk assessment

- dietary assessment