ASSESSMENT OF NUTRITIONAL STATUS

Mgr. Dana Hrnčířová, Ph.D.Dpt. of Nutrition, 3rd Faculty of Medicine, Charles University

NUTRITIONAL STATUS (NS) A part of general health status Adequate = good balance between the body's

needs and the intake of nutrients

Malnutrition imbalance between the body's needs and the

intake of nutrients

MALNUTRITION (broadly) undernutrition, overnutrition specific deficiencies

develops in stages: nutrient levels in blood and/or tissues change

intracellular changes in biochemical functions and structure

symptoms and signs appear (morbidity and mortality can result)

well-nourished person

clinically under-nourished person

clinically intoxicated person

irreversible changes

UNDERNUTRITION Protein Energy Malnutrition (PEM)

inadequate intake of macronutrients

  Marasmus

deficiency of protein and non–protein nutrients

Kwashiorkor protein deficiency (oedema)

Marasmic kwashiorkor combined form of PEM

Causes of malnutrition Loss of appetite, anorexia Digestion and absorption disorders Catabolic state – surgery, injuries, endocrine

disorders Loss of proteins and liquids by fistulas, injuries

…

Pain Stress Infection …

Consequences of Undernutrition

PRIMARY:  Protracted wound healing Increased tendency to infections (impaired

immune functions) Hypoproteinosis (oedema) Decreased gut motility Myosthenia (muscle failing) Tendency to thrombosis, embolism Urinary tract infections

SECONDARY:  increased morbidity  prolonged hospitalization time  prolonged recovery time  increased mortality

Consequences of Undernutrition

ASSESSMENT OF NUTRITIONAL STATUS 1) Clinical assessment

nutritional and medical history, dietary assessment

physical examination

2) Biochemical Laboratory Tests

3) Anthropometric Measurements

NUTRITIONAL HISTORY Inevitably intertwined with the medical history Nutritional disorders Basic illnesses Nutrition related illnesses Digestion (diarrhoea, constipation) Weight (stable, variable) Weight loss / gain Loss of liquids? Increased energy demand?

DIETARY ASSESSMENT

Past intake 24-hour recall (week and weekend day) Food-frequency questionaire Diet history / dietary patterns in last 6 months

Current intake Estimated food records Weighed food records

Smoking habits Alcohol consumption Cooking techniques (boiling, frying, grilling, roasting, …)

24 – Hour Record

  food/drink quantity eaten food/drink quantity eaten

morning meal 

                                          

snack 1 

                                   

noon meal 

                                                               

snack 2 

                            

evening meal 

                                                               

late evening meal

                            

night meal 

                                   

Sex: _________ Date of birth: _____________ Weight: _____ kg Height: _____ cm Today’s date: ___________ List all foods and beverages you consumed in past 24 hours:

PHYSICAL EXAMINATION Blood pressure (HT>140/90) Fragility of gum capillaries (paradontosis, vit.

C def.) Somatoscopy

PHYSICAL EXAMINATION - somatoscopy Skin – petechia, dermatitis, hyperkeratosis,

seborea, hyperpigmentation, dry skin, oedema   Head – hair quality, xerophthalmia, lips-angular

cheilitis, tongue-glositis, papilla atrophy, gums-bleeding, teeth-caries, spots

Neck – examination of thyroid gland  Chest – rib abnormalities, exudate Abdomen – acsites, liver size Limbs – oedemas, reflexes, sensation  Skeleton – deformities, fractures, pain   Skeletal muscle – atrophy 

BIOCHEMICAL LABORATORY TESTSSerum proteins

Total protein: 65-85 g/l Albumin: > 35 g/l (malnutrition < 28 g/l) Prealbumin Transferin Retinol binding protein

BIOCHEMICAL LABORATORY TESTS Complete blood count (haematocrit, haemoglobin,

RBC,WBC, lymphocytes, and differential count) Lymphocyte count:

Normal values > 1800/μlMildly reduced 1800 - 1500

Moderately reduced 1500 - 900

Severely reduced < 900

BIOCHEMICAL LABORATORY TESTSPlasma lipids (primary prevention) Triacylglycerides < 1,7 mmol/l Total cholesterol < 5,0 mmol/l LDL-cholesterol < 3,0 mmol/l HDL-cholesterol > 1,0 mmol/l men

> 1,2 mmol/l women

ANTHROPOMETRIC MEASUREMENTS Indexes (to assess body weight) Body circumferences SkinFolds

Rohrer’s index (RI)

RI = body weight (gr) / height (cm)3 x 100

standards: men 1,2 – 1,4women 1,25 – 1,5

Body Mass Index (BMI) BMI is often used as a predictor of future disease risk.

BMI = BODY WEIGHT (kg) / HEIGHT (m)2

BMI as the sole criterion indicating overweight and obesity is only informative up to a certain point!

WHO Classification BMI

Underweight < 18,5

Desirable 18,5 - 24,9

Overweight 25,0 - 29,9

Grade 1 Obesity 30,0 - 34,9

Grade 2 Obesity 35,0 - 39,9

Grade 3 Obesity >40

BODY FAT DISTRIBUTION Not whole body fat but its distribution

determines risk of mortality and morbidity

ABDOMINAL FAT Hyperinsulinemia, dyslipidaemia,

hypertension, glucose intolerance Increases risk of DM II., cardiovascular

diseases

Waist circumference (WC) Waist/hip ratio /WHR)

Waist Circumference Perhaps better indicator of cardiovascular and

metabolic risks of obesity compared with WHR

Classification increased risk High risk

Men > 94 cm > 102 cm

Women > 80 cm > 88 cm

Classification of overweight and obesity according to BMI and

WC

In connection with the risk of some diseases

Classification

of body weight

BMI

(kg/m2)

Classification

of obesity

RISK OF DISEASES

(relative to normal body weight

and waist circumference)

WAIST CIRCUMFERENCE

men ≤ 102 cm

women ≤ 88 cm

men > 102 cm

women > 88 cm

underweight < 18,5   – –

norm

18,5 -

24,9  – –

overweight25,0 -

29,9   increased high

obesity 30,0 -

34,9 I high very high

35,0 -

39,9 II very high very high

extreme obesity ≥ 40 III extremely high extremely high

Waist to Hip Ratio (WHR) Indicator of cardiovascular disease risk

Fat distributed mostly in the abdominal area is associated with higher morbidity and mortality due to cardiovascular disease.

Waist – with abdomen relaxed, horizontal measure taken at the level of the narrowest part of waist below bottom of rib cage and above umbilicus

Hips – while standing erect, horizontal measure taken at a level of maximum circumference of hips

WHR = waist circumference / hip circumferenceClassification Moderately high risk High risk

Men 0,9 - 1,0 > 1,0

Women 0,8 - 0,85 > 0,85

Mid–arm muscle area Used to estimate lean body muscle mass

Derived from the TSF and the mid-arm circumference

Mid-arm circumference - midway between the olecranon process and the acromium, right arm in a relaxed position

Triceps skin fold - midway between the olecranon process and the acromium, on the posterior of the arm over the long head of the triceps brachii.

Mid–Arm Circumference (cm) – 0,314 x Triceps Skinfold (mm)

Muscle Mass Adequate Marginal Depleted Wasted

Men 25,3 - 22,8 22,8 - 20,8 20,8 - 17,7 < 17,7

Women 23,2 - 20,9 20,9 - 18,6 18,6 - 16,2 < 16,2

Measurement of skinfolds Cheek – horizontal fold on a join tragus – nostrils, right bellow the temple

Jowl – vertical fold between chin and laryngeal prominence

Chest – anterior axillary fold (oblique). Diagonal fold taken ½ the distance between the anterior axillary line and the nipple (1/3 distance women).

Axilla – at the intersection of a horizontal line level with the 10th rib and the anterior axillary line.

Triceps – vertical fold on posterior midline of upper arm, midway between the acromion (bony tip of shoulder) and olecranon processes (elbow joint).

Biceps – the pinch position is at the same level as for triceps, though on the anterior (front) surface of arm.

Subscapula - 2 cm below the lower angle of the scapula (bottom point of shoulder blade) on a line running laterally and downwards (at about 45 degrees).

Abdominal – vertical fold, is made 5 cm adjacent to the umbilicus (belly-button) taken on a line running laterally to the spina iliaca anterior

Suprailiac – taken in the anterior axillary line immediately superior to the iliac crest

Thigh – vertical fold above patella

Calf – 5 cm below popliteal fossa

Practical trainingBody circumferences

1. Mid-Arm Circumference Mid-Arm Muscle Area2. Waist Circumference3. Hip Circumference WHR

Skinfolds4. 10 skinfolds % of body fat5. 4 skinfolds % of body fat

Bioelectric impedance (BIA)

Thank you for your attention.