FNN301 - Midterm Lecture 3 Nutrition assessment

Subjective data

• interviews

• interviewers observations

Objective data

• information available from varifiable source

  • medical records and medical history

• Anthrompoetric measures, biochemical data, results of medical tests and procedures

Nutrition screening

• identify individuals who are at nutritional risk and to determine a more detailed assessment is warrented

• usual diet tech, nurse, physician or other qualified health professional

• at risk patients referred to RD

• usually completed within 48 hours of admission

What do we screen for

• malnutrition

• infections and other issues

• can be deficiency and excess of energy, protein or other nutrients

• issues

  • Increased risk of infection

  • increase risk of falls

  • functional decline

  • longer and more complex recovery process

  • increases risk of readmission within 30 days of discharge

  • increased morbidity and mortaliy y

Malnutrition screening - Canadian nutriton screening tool

• short

• easy to use

• valid and reliable for acute and primary care settings

• questions can be asked of friends or family

• does not need to be completed by a nutrition professional

• nurses agree that it is easy use in their admision assessment

Questions in the canadian nutrition screenign tool

• have you lost weight in the past 6 months without trying

• have you need eating less than normal for more than a week

  • 2 yes is nutritional risk

Subjective global assessment

• nutrient intake

• weight

• symptoms

• functional capacity

• metabolic requirement

Three SGA classifications

• A: Well-nourished: no decreased intake

  • <5% weight loss and minimal stmpyoms

• B: Mildly/moderately malnourished: definite decrease in food intake

  • 5-10% weight loss

• c: Severely malnourished: severe deficite in food intake

  • >10% weight loss which is ongoing

5 features of patient history in SGA

• weight change

• dietary intake change

• GI symptoms

• functional capacity

• disease and its relation to nutrition requirements

5 features of SGA physical exam

• loss of subcutaneous fat in the triceps

• muscle wasting in quads and delts

• ankle edema

• ascites

Malnutrition screen tool (MST)

• unplanned weight loss

• appetite

Nutrition risk screen - 2002

• unplanned weight loss

• BMI

• Age

• disease severity

• impared physical contidiont

Malnutrition universal screen tool (MUST)

• unplanned weight loss

• BMI

• disease severity

• food intake

Mini nutrition assessment (MNA)

• appetite

• GI issues

• Unplanned weight loss

• mobility

• BMI

• Stress

ABCD screening and assessment

• anthropometric (direct measure)

  • physical body parameters

• Biochemical (direct measure)

  • blood, urine, feces

• Clinical (Direct measure)

  • clinical signs and symptoms

• Dietary (indirect measure)

  • diet quality, deficiency or excess level of nutrients

Anthropometric

• weight

• height

• BMI

• skinfolds

• waist circumference etc

Biochemical

• blood

  • serum albumin, prealbumin

  • ferritin, b12, folate, glucose, HbA1c, lipids

• Urine

  • urea nutrigin

  • creatinine excretion

  • urinary iodine, sodium and potassium

• Feces

  • fecal fat (24 hour)

  • fecal nitrogen

  • micronutrient loss gut microbiome

Clinical

• wasting

• edema

• muscle loss

• skin and hair

• pale etc

Dietary intake

• 24 hour recall

• FFQ

• diet history

• food diaries and records

Dietary patterns/quality

• Healthy eating index

• DASH score

• mediterranean diet score

• diet diversity score

Household/food environment nutrition indicator

• food security questionnaires

• food availability and access

• meal frequency

Client history

• social history

  • income, SES

  • social and medical support

  • culture and religion

  • housing

  • social isolation vs social connected ness

• Personal history

  • age, occupation, role in family, education level etc

  • household and meal patterns

  • physical acivity

  • appetite

• Medical and health history

  • primary nutrition complaint

  • past and present illnesses and surgurys

  • chronic diseases, family medical history

• Medication and supplement history

  • prescription and over the counter drugs

  • herbal and dietary supplements

  • use of substances

Height

• <2 uses length board

• >2 uses standing height using tape measure or stadometer

  • can also use arm span, knee height if the patient cannto stand

Weight

• electronic scales, wheelchair and bed scales

• amputation calculations has weight /(100 - % amputation)

Growth charts

• birth - 2 years use

  • length for age, weight for age

  • head circumference for age and weight for length

• 2-19 use

  • height for age and weight for age

  • BMI for age also

Adult Anthropometrics

• BMI

• Waist circumference

• Waist to hip ratio

• usual body weight (UBV)

  • weight prior to weight change

• Percent usual body weight and percent weight change

BMI calculation

• Weight in kg/ (Height in m)²

BMI categories

• underweight <18.5

• Normal weight 18.6-24.9

• Overweight 25.0-29.9

• Obese

  • class 1: 30-34.9

  • Class 2: 35-39.9

  • Class 3: >40

Waist circumference

• indicates health risk associated with excess abdominal fat

• measure on torso between lowest rib and pelvic bone or over umbilical

• Measuring tape should be snug but not denting tissue

Waist circumference cut off points

• Men >102cm

• Women >88cm

• Has increased risk of developing health problems

Waist to hip ratio

• waist circumference / Hip circumference

Unintentional weight loss

• most important predictor of protein - calorie malnutrition

• significant and fast weight loss in lean body mass loss

• Overweight and obese people can protein-calorie malnutrition

• assessing weight change/unintentional weight loss is the best way to screen for malnutrition

% usual body weight

• compare current weight with usual weight

• identify is patient is significantly lower than typical weight

• provide additional context when evaluating recent changes in nutrition status

• should be interpreted with weight history, % weight loss, time

• Current body weight / Usual body weight x 100

Ideal Body weight (IBW)

• IBW kg = 22 x [height (m)]²

Adjusted body weight (AdjBW)

• AdjBW = IBW + 0.25 x (actual BW - IBW)

• Tissue above IBW is not entirely metabolically inactive

  • adjusted weight accounts for some additional metabolically active tissue without assuming that requirements increase in direct proportion with actual weight

Body composition measurements

• body composition distribution and size of all components contributing to total weight

  • fat mass and fat free mass

  • primary concern is metabolically active tissue and fluid status

• Most common tools used to assess body composition in nutritional assessment

  • skin fold test

  • bioelectrical imdedance (BIA)

Skinfolds

• estimates energy reserves in subcutaneos tissue

  • minimally invasive with minimal equipment

  • Takes repitition and experience to get consistant and reliable results

BIA (Bioelectrical impedance)

• electrical resistance in body is inversely proportional to total body water

• estimating body composition in body fatt

• Quick, cheap, non-invasive

• Helps track body fat and muscle over time

• Hydration status can over estimate fat with dehydration and underestimate with overhydration

• recent food and exercise can shift body water

• population specific

Biochemical assessment

• measure nutritional markers and indicators found in blood, feces, urine and tissue samples

  • visceral protein assessment

  • immunocompetence - protein deficiency routinely results in increased risk of infection and altered immune response

    • TLC (WBC * percent lymphocytes)

  • Hematological

  • vitamin and mineral assessment

  • other lab measures

Hemoglobin

• Oxygen transport, anemia screening

• detects anemia from iron, folate, or b12 deficiency

Serfum folate and B12

• DNA synthesis

• deficiency causes macrocytic anemia

Albumin

• long term protein status

• reflects chronic malnutrition but slow to respond so albumum could be high even with inadequate protein intake

Prealbumin

• short term protein energy status

• useful to monitor acute changes in nutrition support

Viceral protein status evaluation

• affected by hydration, chronic illness acute phase response

• low sensitivity and specificity

• low serum albumin and acute phase proteins are associated with increased complications and length of stay in hospitalized patients

• low values of albumin in critically ill patients measures severity of illness

• valuable predictor of morbidity and mortality in hospital and LTC patients

Sodium

• fluid balance

• dehydration or overhydration

Potassium

• neuromuscular and cardial purpose

• critical in refeeding, malnutrition, renal disease

Calcium

• bone, nerve, muscle

• Affected by vitamin D and protein status

Magnesium

• enzyme cofactor

• deficiency common in alcoholism and refeeding syndrome

eGFR (Estimated glomerular filtration rate)

• renal function estimate

• guides protein/fluid needs in CKD

• KIDNEYS

Bilirubin

• Liver clearance

• increased liver dysfunction, affects nutrient metabolism

• LIVER

Fasting glucose

• baseline glycemia

• monitors carbohydrate metabolism

HbA1c

• long term glycemia (2-3 months)

• key marker for diabetes and nutrition therapy monitoring

Lipid pannel

• total cholesterol → CV risk → diet and metabolic status infuence

• HDL → Protective cholesterol → increases with physical activity + good fats

• LDL → bad cholesterol (atherogenic) → high with sat fats increase cvd risk

• Triglycerides → cvd risk → elevated in obesity, high carb/alcohol intake

Vitamin D

• bone and immune function

• deficiency is common especially in northern climates

CRP (C-reactive protein) / cytokines

• inflammatory systemic inflammation

• helps interpret nutrition markers

Clinical assessment

• oral health

• general physical apperance

• muscle and subcutaneous fat wasting

• hair, nails, gums etc

Muscle wasting

• temporalis muscle

• toracic and lumbar region

• clavical region

• scapular region

• dorsal hand

• deltoid and acromin region

• anterior thigh and quads

• posterior calfs

fluid status

• edema ankles

• abdomin - ascites

• dehydration (skin dry and turgor)

Subcutaneous fat loss

• orbital fat pads around the eye

• upper arm triceps/biceps region

• mid-axillary just above the iliac crest

Orbital fat pads- subcutaneous fat loss

• eye socket below eye lid above the eye brow

• nourished:

  • slightly buldged

• Mild-moderate malnutrition

  • dark circle with some hollowing

• severe fat loss:

  • dark circles, pronounced hollow apperance, prodominate brow bone

Buccal fat - subcutaneous fat pads

• index and middle finger palpate fat pads below the cheek above the jaw looking for sunken look or hollowing

Triceps subcutaneous fat loss

• ask patient to bend arm at 90 degrees, pinch skin and determine the amount of fat

  • pinch and roll down to separate the muscle from fat

• Nourished: ample fat tissues between skin folds

• Mild-moderate loss: slightly loose skin, fingers almost tough some depth to pinch

• severe fat loss: loose skin, very little space between folds

Temporalis muscle

• view patient from front

• paplate in a scoping motion to see muscle mass and loss

Clavicle region

• patient sitting upright to examine the collar bone and muscles around the clavicle

• press down above collarbone and fingers should not slide under the collar bone

• Nourished

  • visible but not prominant in women, not visible or partially in men

• Mild-moderate visible in males, protrusion in females

• Severe muscle loss: protruding and prominent bone

Skin assessment nutrients

• vitamin c:

  • hyperkeratosis follicular

  • poor wound healing

• Zinc

  • poor wound healin g, dermatitis

• Niacin

  • dermatitis in the sun exposed areas

hair assessment nutrients

• protein energy malnutrition

  • thin sparce hair, changes in colour and texture

• Vitamin C

  • corkscrew hairs

Eyes assessment nutrients

• iron, folate, vitamin B12

  • pale conjunctivae (pale red under eye)

• Vitamin A

  • night blind

  • conjunctival, dryness

  • bitot spots

  • keratomalacia

Lips and mouth assessment nutrients

• riboflavin, niacin, vitamin B6

  • cheliosis

  • angular stomatitis (cracking at corner of mouth)

  • erythema (red lips)

Tongue assessment nutrients

• B12, riboflavin, niacin, b6 iron and zinc

  • glossitis (smooth, red tongue with loss of papillae)

  • dysgeusia (altered or loss of taste)

Neck assessment nutrients

• iodine

  • enlarged thyroid (goiter)

Dietary assessment challenges

• error

  • database of foods and nutrients

  • food records accuracy

  • data entry errors

  • interpretation

• Obtaining accurate information

  • changing intake while recording

  • seasonal fluctuations

  • issues estimating portions

• Need a large number of days to estimate nutrient intake averages

• nutrients in large amounts in few foods require months and years to estimate the average intake

  • nutrients in small amounts in many foods require fewer days of data

24 hour food recall

• low burden, high compliance, cheap and easy

• relies on memory

• need to estimate portion sizes

• need to be well trained to administer

Estimated or weighted food record

• document intake over specified time period

• estimates agerage intake of individuals

• everything for 3 non consecutive days

• estimated or weighted

• must have 1 weekend 2 weekdays

FFQ

• estimated usual consumption of individuals

• frequency of each category

• time frame

  • year, month etc

• general or a focus on specific foods to estimate intake of nutrients or non nutrients

• Quantitative (portion size estimate) semi-quantitative

FFQ advantage and disadvantage

• low response burden

• high response rate

• interviewer administrated or self administered

• fast and cheap, culturally appropriate

• Validity is unclear

• relies on memory

• gathers data on food included on food list

Nutrition care indicator: observation of food intake

• food weighed before and after eating

• actual food intake is obeserved

• used in LTC and hospitals

Indirect calorimetry

• gold standard of energy requirement

• total energy requirement based on

  • basal energy expenditure (BMR)

  • energy for PA

  • thermic effect of food

Basal energy

• physiological functions to maintain life

• 605 of energy requirement

• RMR is 10% higher than BMR

Factors influencing energy expendature

• age

• growth

• physical activity

• body composition (Leab body mass vs fat mass)

• body size

• clinical status, infection, wound healing

• HIGHEST IMPACT FROM BURNS

Stress factor effect on energy order

• Burns

• sepsis/infection

• trauma

• surgery

• stable chronic disease