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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Continued.. An estimation based on information obtained from :

Historical Information Anthropometric measurement Physical examination (clinical and physical) Laboratory examination (biochemical)

Historical Information
Health history Sosioeconomic history Drug history Diet history
QUALITATIVE METHOD Dietary history Food frequency

QUANTITATIVE DAILY CONSUMPTION METHOD. recall (24 hours, 48 hours) record (1-7 days ) weighed food records estimates of actual recent

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 food b. 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

sometim es

Rice noodles potatoe s 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
Body height is measured with microtoise 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) Continue.. Take note

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

BODY WEIGHT
Instrument : balance scale, max. 140 kg

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

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

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

BH/age : Determining nutritional deficiency in the past/during growth

Recommended by Medical Nutritionist To establish DBW (desirable body weight) only by Clinician Reducing body weight - 1 Kg/week Reducing body weight must be step by step Dont skip meal (especially breakfast)

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Determination body weight

If < 30 years Normal 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 years Normal 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 )

The ratio of BW/BH is termed 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

For e. g BH = 160 Cm BW = 70 Kg BMI = BW/ BH ( m ) = 70 / (1,6)2 = 27.34 (you may use Nomogram or WHO classification and disease risks BMI = Weight (Kg) Height (m ) = a definition of the level of adiposity Waist circumference : Normal : Female < 0.8 Male < 0.9 Theres 2 type : 1. Apple type if Waist circumference > hip Risk faktor : coronary Heart disease 2. Pear type if Waist circumference < hip Risk faktor : - DM, Varices

How to use Nomogram

Measurement of Skin folds Thickness (SF)

Used skin fold caliper Lange

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

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 patients 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)

The following are characteristics of a sufficiently-fed person :

Responsive Gleaming eyes Shiny hair Good complexion Normal appetite

CLINICAL EXAMINATION
Anamnesis, i.e. questions regarding

Complaints Daily food intake Eating habit Consumption pattern

Physical:

Observation Palpation Auscultation

Clinical Examination:

Usually non-specific symptoms Only suitable for moderate and advanced malnutrition For early malnutrition other examinations are needed

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 decrease CHI = 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 obligatory N loss (2-4) g N intake = prod (gr) intake 6.25 N balance = protein intake (gram/day) UUN + 4 6,25 UUN = urea urine nitrogen 4 = 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 /mm moderate protein depletion 800 1199 /mm severe < 800 /mm

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 patients nutritional intakes, metabolism state, current illness Duration of the immune deficit

Understanding Nutrition, From appendix pages E1 E23

Krauses : 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