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Nutritional Assessment

NUTRITIONAL ASSESSMENT

Nutritional assessment refers to the condition of the body related to the intake and use of nutrients.

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An estimation based on information obtained from :

• Historical Information• Anthropometric measurement• Physical examination (clinical

and physical) • Laboratory examination

(biochemical)

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Historical Information

• Health history• Sosioeconomic history• Drug history• Diet history

QUANTITATIVE DAILY CONSUMPTION METHOD.

•recall (24 hours, 48 hours)•record (1-7 days )•weighed food records estimates of actual recent intakes

QUALITATIVE METHOD

•Dietary history•Food frequency

FOOD RECALL METHOD (RESTROSPECTIVE DATA)

• respondent or parents are asked by nutritionist has been trained

• recall the respondent exact food intake during the previous 24 hour period or 2 x 24 hour period

• all foods and beverage consumed (including snacks)

• quantity• price, brand names ( if possible )• vitamine and mineral supplement use

is also noted • purchase value

FOOD RECALL METHOD (RESTROSPECTIVE DATA)

• usually the preceding 1-7 days • used food models ( as memory aids )• information on the characteristics of

each food ( e.g. canned, fresh or frozen, enriched or unenriched )

• the number of meals eaten both at home and away from home

• quantities of foods consumed are usually estimated in household measures and

• entered on data sheet (use food composition table converted into grams)

Flat slop syndrome may be a problem in 24 hour recall method, in this syndrome, individual appear to over estimate low intakes and under estimate high intakes, sometimes referred to as talking a good diet.

FOOD RECORDS • respondent record at the time consumption

all foods and beverage (including snacks) • usually completed over at least a one-week

period • brand names, price• preparation and cooking are recorded • standart household measuring cups and

spoons and counts ( for eggs )• portion size measure are usually converted

into grams by investigator before calculating nutrient intakes ( use Food Composition Table=DKBM/Daftar Komposisi Bahan Makanan )

• usually 3, 5 or 7 days are used

WEIGHED FOOD RECORD• weigh all foods and beverage

including snacks consumes by the subject during a specified time period

• details of methods of food preparation, description of foods and brand names

DIETARY HISTORY• to estimate the usual food intakes of

individuals over a relatively long period of time

• carried out by a nutritionist trained• the general information obtained includes

detailed descriptions of foods, their frequency of consumption and usual portion size

• typical questions might be:” what do you usually eat for breakfast

• cross check for the information on usual intake obtained from the first stage

• frequency of consumption of specific food items

FOOD FREQUENCY QUESTIONAIRE (RESTROSPECTIVE DATA)

• qualitative• descriptive information about

usual food consumptions pattern• the questionnaire consist of 2

components :a. list of foodb. a set of frequency of use response

categories

List of the food

Amount 3 times a day

2 times a day once aday

6 times a week

5 times a week

4 times a week

3 times a week

2 times a week

One a week

sometimes

Rice

noodles

potatoes

cassava

Anthropometric Measurements

• Measures of Growth and Development– Height– Weight– Head Circumference

• Measures of Body Fat and Lean Tissue– Fatfold Measures– Waist Circumference

BODY HEIGHT

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• Must be calibrated• Accuracy up to 0.1 cm • Standing bare footed • Standing relaxed, backwards

towards the meter• Back of head, back, behind touch the

meter and forming a straight line • Straight sight, chin parallel to the

ground • Lower microtoise until it touches the

head • Read (up to 0.1 cm)• Take note

Body height is measured with microtoise

If BH is lower than standard, energy/protein deficiency has happened for a prolonged period during growth (especially protein)

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BODY WEIGHT

• Must be calibrated• Minimally dressed• At the same time and condition

every day • Standing relaxed• Straight position • Chin parallel to the ground • Weight noted up to 0.1 kg

Instrument : balance scale, max. 140 kg

By measuring relative BW : BW (kg)/BH (BH in cm – 100) . 100%The above formula is often used by clinicians and is related with relative risk factors for :

• Mortality • Morbidity• DM• Hyperlipidemia • Hypertension • Coronary heart disease

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The following combinations are possible : – BW/A, BH/A A = age – Combinations : BW and BH, SF at 4

spots, extremity circumferences (mid arm)

Measurement results vary depending on : – Age– Sex– Nutritional condition, i.e. energy and

protein

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BODY WEIGHT/BODY HEIGHT

• Is a sensitive index of nutritional status

• Hurdle : the presence of edema prevents the use of BW as a determining parameter SF and circumference measurements are needed

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BH/age : • Determining nutritional deficiency

in the past/during growth

To determine BW difference, a comparison is made between the current and the usual BW

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Recommended by Medical Nutritionist

• To establish DBW (desirable body weight) only by Clinician

• Reducing body weight ½ - 1 Kg/week

• Reducing body weight must be step by step

• Don’t skip meal (especially breakfast)

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Determination body weightIf < 30 yearsNormal BW = (BH – 100) – (10% (BH – 100))

e.g. BW = 70 Cm Normal BW = (170 - 100) – (10% (170 – 100))

70 – 7 = 63 Kg 100%If > 30 yearsNormal BW = (BH – 100)

= 170 – 100 = 70 Kg 100% Over weight : 110 – 120 %Obesity : > 120%

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•Body frame type

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Profession ( e.g. mannequin, athlete etc)

BMI (Body Mass Index = Quetelet index )

• for most adult • indirect mesures of obesity • easy, quick and more prcise than skin fold

(SF) • cannot be used to distinguish between

excessive weight produced by adiposity, • muscularity or edema • more direct measure of obesity, such as SF

The ratio of BW/BH is termed Body Mass Index = Quetelet Index

For e. g BH = 160 Cm BW = 70 Kg BMI = BW/ BH ( m² ) = 70 / (1,6)2 = 27.34(you may use Nomogram or WHO classification and disease – risks BMI = Weight (Kg) Height (m² )

= a definition of the level of adiposity

Waist circumference : Normal : Female < 0.8

Male < 0.9 There’s 2 type : 1. Apple type if Waist circumference > hip Risk faktor : coronary

Heart disease2. Pear type if Waist circumference < hip Risk faktor : - DM, Varices

How to use Nomogram

Measurement of Skin folds Thickness (SF)

• must be calibrated• usually at 4 spots :

– Triceps skinfold : measured at mid point of the back of the upper left arm

– Biceps : as the thickness of vertical fold on the front of the upper left arm

– (acromion – oleceranon – mid point) – Subscapular skin fold measured just below and

laterally to the angle of the left shoulder blade with the shoulder and left arm relaxed

– Suprailiaca skin fold measured in the mid axillary's line immediately superior to the iliac crest

Used skin fold caliper Lange

Mid upper arm :• Taken at the midpoint between the

acromial and olecranon • Tend to parallel changes in muscle

mass • Particularly useful in the diagnosis of

PEM or Starvation • Used to monitor progress during

nutritional therapy • The arm should hang relaxed at the

patient’s side • Non stretch tape made of fiber glass or

steel

Physical examination • Examination of the following

organs : – Eyes– Mucosal membrane – Skin – Hair– Mouth– Teeth– Glands – Lower extremities (edema)

• Responsive• Gleaming eyes• Shiny hair • Good complexion• Normal appetite

The following are characteristics of a sufficiently-fed person :

CLINICAL EXAMINATION

• Complaints• Daily food intake • Eating habit • Consumption pattern

Anamnesis, i.e. questions regarding

• Observation • Palpation • Auscultation

Physical:

• Usually non-specific symptoms• Only suitable for moderate and

advanced malnutrition • For early malnutrition other

examinations are needed

Clinical Examination:

LABORATORY EXAMINATION(BIOCHEMICAL)

Assessment of Protein Status • to estimate avaibilability in biological

fluids and tissues • allow assessment of clinical,

subclinical nutrient deficiencies • objectives data used in assessing

nutritional status • to eliminate the inevitable

inconsitency associated subjective judgment

LABORATORY EXAMINATION(BIOCHEMICAL)

Assessment of Protein Status Assessment the others nutrients

I.Test of body composition – 3 methyl histidine in urine in (24 hour) – creatinine – height index (CHI)

II. Test of Catabolism Protein – nitrogen balance

III. Test of synthesis protein visceral– albumin– transferrin– RBP

IV. Test immunological – TLC– Hb– Skin test

I.a. 3 methyl histidine : – an amino acid found only in muscle – excretion related to muscle mass – not useful in stressed patients or after intense muscular

activity b.CHI

– excretion related to muscle mass – limitation (diet meat, stress) creatinine increase, age and

renal insufficiency decreaseCHI = CHR(subject) x 100% CHR (ideal) CHR (creatinine hight ratio) % deficit = 100 – CHI (%) deficit 5 – 15% = mild 16 – 30 % = moderate .> 30 % = severe

II. Nitrogen Balance Nitrogen Intake Nitrogen output = UUN plus obligatoryN loss (2-4) g

N intake = prod (gr) intake 6.25

N balance = protein intake (gram/day) – UUN + 4 6,25

UUN = urea urine nitrogen4 = nitrogen loss from feces and skin/sweat

if negative = catabolism 0 = catabolism + = anabolism

III. a. Albumin• large body pool (3-5 gram/kg BW) • normal 3.5 – 5 gram/100 cc serum • mild protein depletion 2,8 – 3,5

gram/100 cc serum• moderate protein depletion 2,1 – 2,7

gram/100 cc serum • severe protein depletion < 2,1

gram/100 cc serum

b. Transferrin– normal 200 – 300 mg%– mild protein depletion 150 –

200 mg%– moderate protein depletion

100 – 150 mg%– severe protein depletion < 100

mg%

C. RBP–very sensitive –half life 12 hour–pool body size 2 mg/kgBW–normal 2.1 – 6.4 mg/dl

IV. a. TLC• mild protein depletion 1200 – 2000 /mm³• moderate protein depletion 800 – 1199 /mm³• severe < 800 /mm³

b. Hb• normal male 16 gr% • normal female 12 gr%

c. Skin test• Evaluation of immune competence in relationship to

nutritional status • Requires precise knowledge of patient’s nutritional

intakes, metabolism state, current illness• Duration of the immune deficit

• Understanding Nutrition, From appendix pages E1 – E23

• Krause’s : Food, Nutrition and Diet Therapy pg 361 – 378

• Gibson RS : Principles of Nutritional Assessment pg 4 – 52, 86, 97 –102, 182, 182 - 190, 307 – 320

• Przytulski & Lutz : Nutrition and Diet Therapy pg 11 – 16, 30

• Shils : Modern Nutriotion in Health Disease pg 851 – 852