macronutrients: muscle and fat mass assessment andrea k. jevenn, rd, ld, cnsc baltimore, june 12,...
TRANSCRIPT
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MACRONUTRIENTS: MUSCLE AND FAT MASS
ASSESSMENT
Andrea K. JeVenn, RD, LD, CNSC
Baltimore, June 12, 2015
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OBJECTIVES
Understand the reason for performing a nutrition focused physical exam (NFPE)
Demonstrate a technique to accurately identify and grade malnutrition-related muscle and subcutaneous fat loss
Practice the demonstrated NFPE technique
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STEPS FOR DIAGNOSING MALNUTRITION
Step 1 – Determine Etiology:
Social / Environmental Circumstances
Chronic Illness Acute Illness or InjuryStep 2 – Eval
Characteristics: Energy Intake * Weight Loss
Muscle Mass Loss * Body Fat LossFluid AccumulationHand Grip Strength
> 2 characteristics?
YES!
1 characteristic? NO
Step 3 – Is Pt Malnourished?
MODERATE
SEVERE
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WHAT IS NFPE?Exam which uses physical assessment and physical function findings to help determine nutritional status and diagnose malnutrition
Components Macronutrient-
Fat (orbital, triceps, ribcage) Muscle (temples, shoulders, clavicles, scapula, thigh, calves) Fluid-extremitiesMicronutrient-
Skin, Nails, Hair, Head/neck, Oral cavity, Eyes, Nose/Face
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WHY SHOULD DIETITIANS USE NFPE? Reveals & confirms problem areas that indicate
malnutrition & micronutrient deficiencies Academy has made the NFPE a standard of
practice for RDs starting in 2012 Subjective Global Assessment (SGA)
Looks similar to newest adult malnutrition criteria - energy intakes, weight changes, muscle & fat loss, fluid status, functional capacity
SGA has been validated in multiple patient populations as a tool to assess malnutrition
ASPEN-Academy criteria was created to be a more objective framework for assessing malnutrition
Baker JP, et al. Nutritional assessment: a comparison of clinical judgment and objective measurements. NEJM, 1982.Detsky AS, McLaughlin JR, et al. What is subjective global assessment? JPEN, 1987.
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SGA VS NEW CRITERIA
SGA ASPEN-Academy Criteria
Weight Changes 1 week 12 months
Nutrition Intake Changes
5 days 1 month
Eval of GI Symptoms
Eval Functional Status
grip strength
Disease Process acute, chronic inflammation vs. no inflammation
Fat Stores eyes, upper arms, mid-axillary line
Muscle Wasting temporalis, pectoralis/deltoids/trapezius, interosseous, quads/gastrocnemius
Edema/Ascites extremities, sacral/scrotum/vulva
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Inspection Most frequently used Broad observation followed
by closer look Critical evaluation
Palpation Examining body structures,
pulsations by touch
HOW TO DO ITTECHNIQUES OF THE PHYSICAL EXAM
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KEEP CALM. PREPARE YOURSELF.
Review the medical record, social history, labs, medications
Gather necessary equipment Wash hands Wear gloves/PPE when
appropriate
Obtain patient’s nutrition history
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PREPARE THE PATIENT.
Introduce self & explain the process
Respect patient privacy & ask permission Draw curtains, close doors Expose areas of body only as
needed
Use professional language
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Exam Area: Temples - Temporalis MuscleView patient when standing directly in front of them,
ask patient to turn head side to sideSevere Mild -Moderate Normal
Hollowing, scooping,
depressionSlight depression
Can see/feel well-defined muscle
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Exam Area: Oribital Area - Fat Pad Around Eye
View patient when standing directly in front of them, touch above cheekbone
Severe Mild -Moderate Normal
Hollow look, depressions, dark circles, loose skin
Slightly dark circles, somewhat
hollow look
Slightly bulged fat pads. Fluid
retention may mask loss
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Exam Area: Clavicle & Acromion Bone - Deltoid Muscle
Patient arms at side; observe shapeSevere Mild -Moderate Normal
Shoulder to arm joint looks square. Bones prominent.
Acromion protrusion very prominent
Acromion process may slightly
protrude
Rounded, curves at arm/shoulder/neck
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Exam Area: Scapular Bone Region Trapezius, Supraspinatus, Infraspinatus
Muscles Ask patient to extend hands straight out, push against
solid object. Severe Mild -Moderate Normal
Prominent, visible bones,
depressions between
ribs/scapula or shoulder/spine
Mild depression or bone may show
slightly
Bones not prominent, no
significant depressions
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UPPER ARM ASSESSMENT TECHNIQUE
Severe
Mild -Moderate
Normal
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BeforeAfter
Exam Area: Upper Arm Region - Triceps/Biceps
Arm bent, roll skin between fingers, do not include muscle in pinch
Severe Mild -Moderate NormalVery little space between folds, fingers touch
Some depth pinch, but not ample
Ample fat tissue obvious between
folds of skin
Keys A. JAMA. 1948;138:500-511
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Exam Area: Dorsal Hand - Interosseous Muscle
Look at thumb side of hand; look at pads of thumb when tip of forefinger touching tip of thumb
Severe Mild -Moderate Normal
Depressed area between thumb-
forefingerSlightly depressed
Muscle bulges, could be flat in
some well nourished people
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Exam Area: Thoracic & Lumbar Region – Ribs, Lower Back, Midaxillary Line
Have patient press hands hard against a solid objectSevere Mild -Moderate Normal
Depression between the ribs very apparent; iliac crest very
prominent
Ribs apparent, but depressions less pronounced;
iliac crest somewhat prominent
Chest is full, ribs do not show. Slight to no
protrusion of the iliac crest.
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Exam Area: Anterior Thighs – Quadriceps
& Patellar RegionAsk patient to sit, leg propped up, knee bent
Grasp quads to differentiate muscle vs. fat tissueSevere Mild -Moderate Normal
Depression/line on thigh, obviously thin
Bones prominent, little sign of muscle around
knee
Mild depression on inner thigh
Knee cap less prominent, more
rounded
Well rounded, well developed
Muscles protrude, bones not prominent
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Exam Area: Posterior Calf Region - Gastrocnemius Muscle
Grasp the calf muscle to determine amount of tissueSevere Mild -Moderate Normal
Thin, minimal to no muscle definition
Not well developed
Well-developed bulb of muscle
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THINGS TO CONSIDER: ETIOLOGY OF MUSCLE WASTING
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CAUSES OF MUSCLE ATROPHY
Amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease)
Polio Guillain-Barre syndrome Motor neuropathy (such
as diabetic neuropathy) Injury Burns Long-term corticosteroid
therapy
Muscular dystrophy Not moving
(immobilization) Osteoarthritis Dermatomyositis and
polymyositis Rheumatoid arthritis Spinal cord injury Stroke Malnutrition
http://www.nlm.nih.gov/medlineplus/ency/article/003188.htm
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SUMMARY: FAT LOSS
3 areas Orbital Region Upper Arm Area
Triceps Biceps
Thoracic & Lumbar Regions Rib cage Lower back Mid-axillary line
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SUMMARY: MUSCLE LOSS
Upper Body Temporalis Clavical Bone Region
Pectoralis Major, Deltoid, Trapezius
Acromion Bone Region Deltoids
Scapula Bone Area Trapezius,
Supraspinatus, Infraspinatus
Hands (Interosseous Muscles)
Lower Body Patellar Area Anterior Thigh
(Quadriceps) Posterior Calf
(Gastrocnemius)