NSC 325 Week 2 Notes

ADIME: A = Assessment

• ADIME framework used for Nutrition Assessment

• A = Assessment

  • Always determine nutrition risk: risk for becoming malnourished

  • Then determine if the patient is malnourished

  • Under Assessment: A, B, C, & D

  • A = Anthropometrics

  • B = Biochemical Data (Labs)

  • C = Clinical Status

  • D = Food & Nutrition History (diet)

Malnutrition criteria (Table 3) – Acute illness or injury

• Clinical characteristic: Energy intake

• Interpretation of weight loss for acute illness/injury

  • Moderate Malnutrition

  • <75\% of estimated energy requirement for >7 days

  • Weight loss: $1\%-2\%$ in 1 week; $5\%$ in 1 month; $7.5\%$ in 3 months

  • Severe Malnutrition

  • <50\% of estimated energy requirement for >5 days

  • Weight loss: >2\% in 1 week; >5\% in 1 month; >7.5\% in 3 months

• Malnutrition in the context of Acute Illness or Injury summary

  • E.g., energy intake and weight loss thresholds drive classification

Malnutrition criteria – Chronic illness (Table 3)

• Moderate Malnutrition

  • <75\% of estimated energy requirement for ≥ $1\ month$

  • Weight loss: $5\%$ in 1 month; $7.5\%$ in 3 months; $10\%$ in 6 months

• Severe Malnutrition

  • <75\% of estimated energy requirement for ≥ $1\ month$

  • Weight loss: >5\% in 1 month; >7.5\% in 3 months; >10\% in 6 months; $20\%$ loss in 1 year; >20\% loss in 1 year

• Important: MALNUTRITION IS UNDERNUTRITION

• Note: Malnutrition can occur at any BMI

Physical findings in malnutrition (Table 3)

• Body fat (subcutaneous fat) loss

  • Severity: mild → moderate → severe (as context requires)

• Muscle mass (muscle loss)

  • Sites for observation: temporal, buccal wasting; triceps/biceps region; clavicular, pectoralis major; scapular; dorsal hand; gastrocnemius

  • Severity: mild → moderate → severe

• Fluid accumulation

  • Localized fluid accumulation (e.g., edema)

  • Severity: mild → moderate to severe

  • Special note: vulvar/scrotal edema may be observed

• Reduced grip strength

  • Measurably reduced grip strength (marker of functional status)

• Diagnostic rule: NEED 2 CRITERIA

  • At least two criteria are required to diagnose malnutrition (per this framework)

• Evidence on exam examples are listed to guide assessment

Key points related to Biochemical data (CMP/BMP)

• CMP/BMP are available for assessment but have limitations

• They provide information about fluid status, acid-base status, glucose, and organ function

• They do not reflect:

  • Specific chronic diseases (e.g., heart disease, cancer, hypertension, etc.)

  • Overall nutritional status alone

• Primary use: screening to indicate where further information is needed

Example labs (Medscape data) – interpretation context

• Glucose = $95\, mg/dL$ (Ref: 65–100 mg/dL)

• BUN = $15\, mg/dL$ (Ref: 8–25 mg/dL)

• Creatinine = $1.1\, mg/dL$ (Ref: 0.8–1.4 mg/dL)

• Calculated BUN/creatinine ratio = 14\$ (Ref: 6–28)

• Sodium = $140\, mEq/L$ (Ref: 133–146 mEq/L)

• Potassium = $4.4\, mEq/L$ (Ref: 3.5–5.3 mEq/L)

• Chloride = $104\, mEq/L$ (Ref: 97–110 mEq/L)

• Carbon dioxide (bicarbonate) = $22\, mEq/L$ (Ref: 18–30 mEq/L)

• Calcium = $10\, mg/dL$ (Ref: 8.5–10.5 mg/dL)

• Protein, total = $7.6\, g/dL$ (Ref: 6.0–8.4 g/dL)

• Albumin = $4.7\, g/dL$ (Ref: 2.9–5.0 g/dL)

• Calculated globulin = $2.9\, g/dL$ (Ref: 2.0–3.8 g/dL)

• Calculated A/G ratio = $1.6$ (Ref: 0.9–2.5)

• Bilirubin, total = $0.4\, mg/dL$ (Ref: 0.1–1.3 mg/dL)

• Alkaline phosphatase = $103\, U/L$ (Ref: 30–132 U/L)

• AST = $10\, U/L$ (Ref: 5–35 U/L)

• ALT = $24\, U/L$ (Ref: 17–56 U/L)

• Source: Lab Med © 2007 American Society for Clinical Pathology

Basic Metabolic Panel: Non-nutritional & Nutritional Impact

• Sodium: reflects fluid/hydration status; not a direct measure of sodium intake

• Potassium: dietary intake can impact, usually more affected by kidney function; diuretics can lower potassium levels; kidney disease can raise; shock, crush injuries, hemolyzed samples can raise K; insulin can lower K

• Medications impacting K: diuretics (e.g., furosemide/Lasix, HCTZ) commonly decrease potassium when dietary intake is not compensated

• Chloride: not a strong dietary factor; reflects acid/base status; affected by hydration status

• BUN: elevations with renal disease, dehydration, GI bleed; high-protein intake with reduced kidney function; low BUN with malnutrition/overhydration; to better assess kidney function check GFR (normal > $90\, mL/min/1.73\, m^2$; renal disease < $60\, mL/min/1.73\, m^2$)

• Creatinine: elevated with renal disease, protein catabolism/muscle damage, dehydration; decreases with malnutrition and overhydration

• Calcium: low albumin requires correction of serum calcium; influences include vitamin D status, other diseases; multiple factors can modify calcium values

• Drug, cancer, bedrest, hyperparathyroidism can alter calcium/other CMP components

Test your knowledge (CMP-based questions)

• True/False: If CMP shows sodium = $150\, mEq/L$ (normal 135–150), high Na can be due to eating foods high in sodium.

  • Answer: False. Serum Na primarily reflects fluid status; dehydration increases Na, not dietary sodium per se.

• True/False: A high Na more often reflects hydration status than intake; dehydration leads to higher serum Na and related increases in Cl, BUN, creatinine, albumin, hematocrit.

  • Answer: True. Serum Na is a surrogate for hydration status more than Na intake.

Case-based reasoning: Potassium, weight loss, and refeeding risk

• Scenario: CMP shows K = $3.5\, mEq/L$ (normal 3.5–5.0) with 10% weight loss over 3 months

  • Likely indications:

  • Fluid overload vs dehydration vs refeeding syndrome vs anemia

  • Correct interpretation (explanation): The combination of weight loss and malnutrition with a low-normal K is a red flag for refeeding risk; requires close monitoring of Mg, phosphate, K at baseline and during nutrition support; also consider thiamine supplementation and higher needs during refeeding

True/False knowledge checks: Albumin as a nutrition marker

• True/False: Maureen’s albumin level of 2.8 (normal 3.5–5.0) confirms malnutrition.

  • Answer: False. Albumin is a poor nutrition marker because it is influenced by stress, inflammation, liver/kidney disease, hydration, etc.; should not be used alone to diagnose malnutrition

Glucose interpretation: Inflammation, metabolic syndrome, steroids, etc.

• Alex’s fasting glucose = $123\, mg/dL$ (normal 70–99)

  • Suspected contributing factors: inflammation; metabolic syndrome; possible steroid use; all of the above

• Note: A1C provides longer-term context (approx. 3 months)

Hypermetabolism and protein needs in illness (ebb and flow phase)

• The ebb and flow phase drive hypermetabolism during illness

• Dietitian role: assess how hypermetabolic a patient is to adjust calorie and protein needs

• Question (example case): Kieran, 26 y/o with leukemia in hospital, dehydration, chemotherapy every 3 weeks

  • Protein recommendation options:

  • $1.0\ \text{g/kg}$

  • $1.2\ \text{g/kg}$

  • $0.8\ \text{g/kg}$

  • $2.0\ \text{g/kg}$

  • Correct: $1.2\ \text{g/kg}$ under moderate stress

  • Rationale: Moderate stress warrants increased protein; 0.8 g/kg is the minimum RDA for healthy adults; 2 g/kg is for very high stress; 1.0 g/kg would be for low-level stress

Nutrition assessment workflow: Comprehensive assessment and NFPE

• Comprehensive Assessment Includes (Head-to-Toe):

  • Survey of overall health

  • Head and neck: hair, face, eyes, nose, oral cavity (lips, buccal mucosa, teeth/gingiva, tongue, hard & soft palate, uvula), neck

  • Neurological system: cranial nerves, dysphagia screen

  • Skin/nails

  • Cardiac/respiratory systems: vital signs (temperature, heart & respiratory rates, pulse)

  • Note signs of muscle & fat loss (clavicles, scapular & lumbar regions); note signs of excess fat as well

  • Abdomen

  • Upper & lower extremities

• NFPE (Nutrition-focused Physical Exam) Key Points

  • Describe the head-to-toe approach of NFPE

  • Understand criteria gathered during NFPE to determine malnutrition (fat and muscle loss required)

  • Describe physical signs of fat & muscle loss observed in NFPE

  • Describe signs of micronutrient deficiencies on skin, hair, nails; in the oral cavity

  • Describe signs reflecting hypervolemia or hypovolemia

Comprehensive malnutrition table (physical findings) – recap

• Physical Findings: Malnutrition indicators

  • Body fat: Loss of subcutaneous fat (severity ranges: mild to moderate to severe)

  • Muscle mass: Muscle loss (sites listed above) with severity (mild → moderate → severe)

  • Fluid accumulation: Localized edema; severity (mild → moderate → severe); may be evidenced by edema in extremities or vulvar/scrotal areas

  • Reduced grip strength: Measurably reduced

  • Note: NEED 2 CRITERIA to classify malnutrition

Disease contexts and exam-ready takeaways

• Diseases commonly associated with nutrition assessment topics: DIABETES, CANCER, NEUROLOGICAL DISEASES, CARDIOVASCULAR INFLAMMATION, ALZHEIMER'S DISEASE, AUTOIMMUNE DISEASES, PULMONARY DISEASES, ARTHRITIS

Final quick-reference: Key thresholds and concepts to memorize

• Malnutrition classification is based on energy intake and weight loss over time, tailored to acute vs chronic illness

• Two or more physical or biochemical criteria are typically required to diagnose malnutrition per this framework

• CMP/BMP provide hydration, electrolyte, and organ function context but do not define malnutrition on their own

• Refeeding risk requires careful monitoring of Mg, P, K and thiamine supplementation when starting nutrition

• Protein needs increase with stress: moderate stress ≈ $1.2\, g/kg$; very high stress ≈ $2.0\, g/kg$; healthy adults minimum ≈ $0.8\, g/kg$

• A/G ratio = $rac{A}{G} = 1.6$ (normal range 0.9–2.5)

• GFR normal > $90\, mL/min/1.73\, m^2$; kidney disease < $60\, mL/min/1.73\, m^2$

• Albumin is not a standalone nutrition marker; influenced by inflammation, hydration, liver/kidney disease, etc.

• Glucose can be affected by inflammation, metabolic syndrome, medications (e.g., steroids); A1C helps assess longer-term hyperglycemia

References to slides and data (examples)

• CMP/BMP interpretation notes (Page 4–6)

• Lab values example (Page 5)

• Basic metabolic panel interpretation (Page 6)

• Test-your-knowledge items and explanations (Pages 7–14)

• Ebb and flow protein recommendations (Pages 16–17)

• Jacklyn case-study questions (Pages 18–21)

• NFPE and comprehensive assessment details (Pages 22–24)

• Reiterations of Table 3 malnutrition criteria (Pages 3 and 24)