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Dr.

I Wayan Weta, MS
School of Medicine
Udayana University/
RSUP Sanglah Denpasar
The purpose of Nutritional
Assessment

IDENTIFICATION OF NUTRITIONAL
DEFICIENCIES
CLASSIFICATION OF
MALNUTRITION
ESTIMATION OF NUTRITIONAL
REQUIRMENTS
Identification Nutrition-Related
Conditions
Nutritional Assessment

ABCD of nutritional
Assessment:
Anthropometric
Biochemical test
Clinical observation
Diet evaluation and
personal histories
Methods of Obtaining Intake
Data
Direct observation and nutrient analysis: can
be used only in controlled settings; doesnt
represent usual intake; calorie counts fall
into this category
Food record or diary: prospective tool; asks
client to record or weigh food intake for a
specific time period
Food frequency questionnaire: retrospective;
asks client to complete a survey about food
intake over a specific time period
24-hour recall: retrospective tool; asks client
about food intake during the previous 24
hours
Diet evaluation and
personal histories
Specific 24-Hour Food Record
Diet History
Periodic Food Record
Food Frequency Questionaire (FFQ),
Semi Quantitative FFQ (SM-FFQ)

The problem under/over-reporting


Food/Nutrition History
Information
Food/Nutrition History
Information contd
Food consumption of
individuals
Quantitative:
Twenty four hour recalls method

Repeated Twenty four hour recalls

method
Estimated food record

Weight food record


24-Hour Recall

Strengths Weaknesses

Less likely to modify Memory dependent


dietary behavior

Quick and inexpensive Overestimates low intake

Low client burden Underestimates high


intake

Literacy independent High-inter-interviewer


variability
Food Records

Strengths Weaknesses
Greater precision than Eating behavior may
single 24-hour recall change
Not memory reliant Literate and numerate
dependent; requires
knowledge of portion
sizes
Considered actual High client burden
intake
Food Frequency
Questionnaire
Strengths Weaknesses
Low client burden Primarily provides qualitative
information
Quick and inexpensive Literate and numerate dependent

Can examine specific Memory dependent


nutrients
Considered usual intake Cognitively difficult since food
list not meal based
Easily standardized
Accuracy improves when
combined with other data
Direct Observation

Strengths Weaknesses
Low client burden High staff burden
Client unaware of Intrusive
assessment
Not memory or literacy Difficult to attain and
dependent interpret
Does not represent usual
intake
Expensive
NCI Food
Frequency
Questionnair
e
Food Diary

Whats wrong with this picture?


Name :_____________________ Date :____/____/____
Adress: _____________________ Day of week : __________________

Time Name of Description of Amount gram


food/drink ingridient (house hold)
6.00-10.00
Breakfast

10.00-12.00
Snack
12.00-13.00
Lunch

13.00-18.00
Snack
18.00-
Dinner
Addition questions:
Was intake unsual in any way? Yes/No
If yes, in what way?

Do you take vitamin or mineral supplement? Yes/No


If yes, how many per mday? (....) per week? (.....)
If yes, what kind? (give brand if posible)

Multi vitamin:_________________________________________

Iron :___ mg, Ascorbic acid:_____mg,

Other (list):
Qualitative Foods
Dietary Assessment
Food History

Foods Frequency Questionaire


(FFQ)

Semi Quantitative Food Frequency


Questionaire (SM-FFQ)
Dietary history
Dietary history (consist of 3 component):
The First : the 24 hours recall of actual intake
The Second: Cross check for information, and usual
portion sizes in common household measures.
The third : a three day foods record using
household measures.
work day,
Saturday,
and Sunday

Average daily intake = 5X work day+Saturday+Sunday


7
Food Frequency Questionaire (FFQ)
Semi Quantitative Food Frequency Questionaire (SQ-FFQ)

Food item Freq/ day Freq/ week Freq/ House gram


month hold
portion
Evaluation of nutrient intake
data
Recommended Nutrient intakes (RNI):
recommended to certain nutrient such as:
protein, Calcium, Phosphorus, iron, vit. A, Vit.
D, Vit. C, Folate, Vit. E, Vit. B12, Magnesium,
Zink, Iodine.
Recommended Dietary Allowance (RDA):
Recommended to almost all of nutrient
Evaluating nutrient intake of
individuals
Nutrient adequacy ratio (NAR):

NAR = subject daily intakes of nutrient


RDA of nutrient
Mean adequacy ratio (MAR):
MAR = Sums of NAR for (X) nutrients
(X)
Evaluating nutrient intake of
individuals
Index of nutritional quality (INQ):
INQ = Amount of nutrient in 1000 kcal of food
Allowance of nutrient per 1000 kcal.
Comparison of individual intake data to RDA
Standard deviation score (Z score):
Z score = individual nutrient intake mean value group
SD value for nutrient for the group.
Body composition and
Anthropometric Measurement
Two Compartment
Fat Mass
Free Fat Mass :
Water
Glycogen
Protein
Mineral
Fat Mass
The averages fat mass of :
- Women: 26.9% of BW
- Men : 14,7% of BW
Fat mass:
- Essential fat
- Reserve (storage) fat
Reserve Fat:
- Men : 12 % BW
- Women : 15% BW
Distributed in :
Inter and intra muscular fat.
Around (and protects) the organ and GIT
Sub-cutan fat
Based on its metabolic activity reserve
fat, divide into:
Peripherally subcutan fat (extremity)
Centrally subcutan fat (in trunkle/body area)
Visceral fat (intra abdominal)
Fat Mass and Obesity
Peripherally subcutan fat (extremity) :
Peripheral , Gynoid, Pear form Obesity.

Centrally subcutan fat (in trunkle/body area):


Subcutan central obesity, Apple form Obesity.

Visceral fat (intra abdominal):


Central, android, Aple form Obesity.
Essential Fat Mass:
- Bone marrow
- Central Nervous system
- Mamma gland
- Etc.
Essential Fat Mass :
- Men 3 % (2,1 kg)
- Women 9% (4,9 kg)
Fat Free Mass
Protein: skeletal muscle, organ muscle.
Mineral
Bodys fluid
BODY COMPARTMENTS
ASSESSED BY
ADIPOSE TISSUE 25% Triceps Skinfold
Body Weight
Arm Muscle
SOMATIC PROTEINS 30% Circumference
Body Weight
Creatinine Height Index

VISCERAL PROTEINS 8% Serum Albumin,


Transferrin
PLASMA PROTEIN 3%

EXTRACELLULAR 20%

SKELETON 10%
Anthropometric
Measurement

Definition:
Measurement various dimension of the
human body, and its composition, in all
level of ages and nutritional status.
(Jelliffe, 1966).
Functions of
Anthropometrical Data
1. Measure the Growth Rate ( in Children)

2. Measure Fat Free Mass (fat free-mass,


lean body mass)

3. Measure Fat Mass (body fat mass)


Growth Measurement
1. Head Circumference
2. Body weigh : infant, children, adult.
3. Body Length and height
4. BW altering
5. Ratio BW/BH
Anthropometrics

Sex (m/f)
Height (H)(cm)
Weight (W)(kg)
Usual weight (UW)(kg)
W as (%) of UW
Ideal Body weight (IBW)(kg)
W as (%) of IBW
Anthropometrics

Triceps skinfold (TSF) (mm)


TSF as (%) of standard

Midle Arm circumference (MAC)

(cm)
MAC as (%) of standard

Midle Arm muscle area (%) of a

standar.
Fatfold Measurements
Courtesy Dorice Czajika-Narins, PhD
IDEAL BODY WEIGHT (IBW).
Hamwi Equetion

Men (kg) = 48 + (H*-152) x 1,06

Women (kg) = 45,4 + (H*-152) x


0,89

* H in cm
Anthropometrics

Weight: Weight loss:


1-2% past week
5% over the past month
7.5% during previous 3 moths
Or 10% past 6 months.

More than this rate--- severe.


Anthropometrics

Height:
Body Mass Index (BMI)
BMI= Weight (kg)/Height2 (m2)
Body Measure:
Mid Arm Circumference (MAC)
Triceps skinfold (TSF)
MAMC = MAC - {3.14XTSF}
Nutritional status based on BMI
and IBW
BMI (kg/m2) Nutritional BW/IBW (%)
>30 state >120
25.1 29.9 Obese 111 -119
18,5 25.0 Overweight 90 110
17,0 -18,4 Normal 80 - 89
16.0 16.9 Mild PEM 70 -79
<16.0 Moderate PEM <70
Severe PEM
CALSSIFICATION OF OVERWEIGHT
AND OBESITY (WHO)

Classification BMI (kg/m2)


Underweight <18.5
Normal range 18.5 - 24.9
Overweight > 25.0
Pre-obese 25.0 - 29.9
Obese class I 30.0 - 34.9
Obese class II 35.0 - 39.9
Obese class III > 40.0
Classification of overweight and obesity by BMI,
Waist Circumference And Risk of co-morbidities.

Class BMI LWC HWC


(kg/m2) <90 cm (men) >90 cm (men)
<80 cm (women) >80 cm (women)

underweight <18.5 Low (but increase others Average


clinical problems)

Normal 18.5-22.9 Average Increase

Overweight 23.0-24.9 Increase Moderate

Obese I 25.0-29.9 Moderate Severe

Obese II >30.0 Severe Very severe


Limitations of BMI

Both men have a BMI of 31


Fat distribution
Gynoid obesity Android obesity
Weight Gain Guidelines

Underweight prior to pregnancy, <18.5


BMI
28 - 40 lbs (12,5-18 kg)
Healthy weight prior to pregnancy, 18.5-
24.9 BMI
25 - 35 lbs (11,5-16 kg)
Overweight prior to pregnancy,24.9-29.9
BMI
15 - 25 lbs (no less than 15 lbs) (7-11,5 kg)
Obese prior to pregnancy, >30 BMI, 15 lb
min (6 kg).
Pregnancy is NOT a time to diet
Pertambahan berat badan
selama kehamilan
BMI + total + TM I + TM II &
(kg) (kg) III
(kg/mgg)
BB kurang 12,5-18 2,3 0,49
(BMI<19.8)

BB normal 11,5-16 1,6 0,44


(BMI 19,8-26)

BB lebih 7-11,5 0,9 0,3


(BMI >26-29)

Obese 6 - -
(BMI >29)
Expected Weight Gain
Grafik pertambahan berat pada kehamilan
Trimaster I Trimaster II Trimaster III
10 kg 10 kg

5 kg 5 kg

0 0
Biochemical
Plasma Protein: Test
albumin,
hemoglobin,
hematocrit;
Additional:
prealbumin,
Thyroxin binding protein,
serum transferrin, or TIBC,
ferritin
Protein metabolism: 24 hour urine test
Urinary
Creatinin High Index (CHI)
CHI = Urinary Creatinine 24 hours X 100%
Expected Creatinin urine in IBW
Expected creatinin urine:
- men = 23 mg/kg IBW/24 hours
- women= 18 mg/kg IBW/24 hours
Interpretation:
- CHI > 80% : normal
-CHI 60-80% : moderate depletion skeletal muscle
-CHI 40-50% : Severe depletion of skeletal muscle
Urinary

N Balanced =
(protein intake:6.25) (urinary urea
Nitrogen+4)

Interpretation:
+ : Anabolic state
0 : Balanced state
- : catabolic state
Biochemical Test
(continued)
Immune System Integrity:
Anergy:
Lymphocyte count (TLC)
Skin testing
Delayed sensitivity (Mumps
or PPD tuberculin)
Biochemical Test
(continiud)
Laboratory Determinations:
Serum albumin (g/dL)
TIBC (g/dL)
Serum transferrin (TFN) (g/dL)
White blood cell count (No/mm3)
Total Lymphocyte count (No/mm3)
24-h urinary urea Nitrogen (g)
24-h urinary creatinine(mg)
CHI (%) standard
OBJECTIVE DATA
SOMATIC COMPARTMENT
MARKER Normal Mild Moderate Severe t 1/2

Albumin > 3.5 3.1-3.5 2.1-3.0 < 2.1 20 d

Transferrin >200 151-200 100-150 <100 8d

Prealbumin >15 10-15 5-10 <5 2-3 d

Total > 2000 1200-2000 800-1199 < 800


Lymphocyte
Count (TLC)
Clinical Observation
Clinical Sign of Malnutrition:
Skin, hair, eye, nail etc
Vital Sign and Physical Examination:
Pulse rate
Respiration
Temperature
Blood pressure
Select appropriate categories with a check mark.
Numerical value are assigned and used for secoring.
Patient may self-report the section 1-4; medical or
nutritional staff will complete number 5,6 and the SGA
score.
SUBJECTIVE GLOBAL
ASSESSMENT (SGA)
1. Weight
2. Food Intake (over past month)
3. Symptoms (longer than 2 weeks)
4. Functional capacity (activity over
the past mounth)
5. Disease and its relation to
nutritional requirement
6. Physical
1. Weight
Weight ________ kg Height _________ cm
Overall loss in past 6 months: Amt.=#______kg
% loss= _______
20%+ = 4 pts;
10-19.9% = 3 pts;
6-9.9% = 2 pts;
2-5.9% =1 pts;
0-1.9% = 0 pts
Overall loss in past 1 month: Amt.+# ______kg;
%loss= _______
10%+ 4 pts;
5-5.9% 3 pts;
3-4.9% 2 pts;
2-2.9% 1 pts;
0-1.9% 0 pts
Change in past 2 weeks:
_____increased (0)
______ no change (0)
_____decreased (1).

2. Food Intake (over past month)


______ No change recently (0)
______ Change:
_____More than usual (0)
_____ less than ususal (1)
Now taking :
_____ normal food but less than normal (1)
_____ litle solid food (2)
_____only liquids (3)
_____only nuytritional supplement (3)
_____very litle of anything (4)
____ only tube feeding or nutrition by vein (5)
Supplement (Circle) : nil, vitamin, mineral #
_______freq. Per week
3. Symptoms (longer than 2 weeks)
____ No problems eating (0)
____ nausea (1)
____ vomiting (3)
____ diarrhea (3)
____ constipasi (1)
____ mouth sore (2)
____ dry mouth (1)
____ Anorexia (3)
____pain(3) ____ (where_____)
____things taste funny or have no taste (1)
____ smells bother (1)
____Other (1) _____________(depression, financial
worries, dental problems, etc).

4. Functional capacity (activity over


the past mounth)
__ Normal with no limitation (0)
__ not ususal, but up and about with normal
activity (1)
__ No feeling up to most thing, but in bed less than
half the day (2)
__ able to do little activity and spend most of the
day in bed or chair (3)
__ seldom out of the bed (4)
6. Physical (for each trait specify :
0=normal, 1+=mild, 2+=
moderate, 3+=severe)
___loss of subcutaneous fat (triceps,
chest) ___ascites
___muscle wasting (quadriceps, deltoid)
___mucosal lession
___ankle edema
___cutanous lessions
___sacral edema
___Hair change
SGA rating (select one):
A
B
C

A _____Well nourished (no weght loss or


recent nonfluid gain; no intake deficit or
recent improvment of noted; no symptom
of nutritional impact; no functional deficit
or recent improvment noted; no physical
deficit or improvment shown recently)

B_____Moderately (or suspected of


being) malnourished ( 5% weght
loss in 1 month or 10% in 6 months;
severe deficit intake; presence of
nutritional impact symptoms;
moderate functional deficit or recent
deterioration; evidence of mild to
moderate loss of subcutaneous fat
and/or musclemass and/or muscle
tone on palpation)
C_____Severely malnourished (over 5%
weight loss in 1 month or over 10% in 6
months; severe deficit intake; presence
of nutritional impact symptom;several
functional deficit or recent functional
deterioration; obvious sign of
malnutrition such as severe loss of
subcutaneous tissues or posible
edema)
Nutritional Diagnosis

Nutrient deficiencies
Underlying disease requiring
modified nutrient or food plan
Personal culture and ethnic needs
Economic need
Drugs information that interact with
food and nutrient
Primary and Secondary
Nutritional Disease
Primary deficiency disease:
Lack of essential nutrient on the
diet
Secondary deficiency disease:
Results from one or more
barriers to use of the nutrient
after consumed food.
Nutrition-Related
Conditions
Two major Nutritional task:
1. Identify person at risk of
malnutrition because of their
disease, injury or life style.
Heart disease, hypertension, diabetes,
liver and renal disease.
Surgery, etc.
2. Analysis of intake to monitor
effectiveness of treatment
Problem List

Concider to every aspects of


patient
Indicators of Nutritional
supporting to Hospitalized
patient :
Albumin serum <5 g/dL
Decresed wight >10%
MAC < centil 5
Limphocyte count < 1200/mm 3
Eating disorder more than a week.
Nutrition Intervention:
Food Plan and Management
Basic concepts of diet
therapy:
Normal nutrition
Disease application
Individual adaptation
Practioner awareness
Nutrition Intervention:
Food Plan and Management
Managing the mode of
feeding:
Oral diet
Tube feeding
Peripheral Vein Feeding
Total Parenteral Nutrition
(TPN)
Evaluating:
Quality Patient Care
General concideration:
1. Estimate the achievement of
nutritional therapy goals.
2. Judge the accuracy of intervention
actions
3. Determine patients ability to follow
the prescribed nutrition therapy
NUTRITION PROGNOSTIC
Prognostic Nutritional
Index (PNI)
Developed by Mullen (1979)
PNI (%) =
158-(16.6*ALB)-(0.78*TSF)-(0.2*TFN)-(5.8*DCH)

ALB (g/dL), TSF (mm), TFN (transferrin) (mg/dL),


DCH (Delayed Cutaneous Hypersensitivity):
0=-, 1=<5mm, 2=>5mm
Risk:
Low :<40%
Intermediate : 40-50%
High :>50%
Nutrition Risk Index
(NRI)
NRI = 15.19*ALB + 0.417* %
UBW

Indicates:
Normal : >100
Mild malnutrition : 97.5-99.9
Moderat to severe malnutrition : <97.5
Hospital Prognostic
Index (HPI)
HPI=
(0.91*ALB)-(1.00*DCH)-(1.44*SEP)
+(0.98*DX)-1.09
ALB(g/dL), DCH: 1=+, 2= -, SEP: 1=+, 2= -, DX: 1=ca, 2=
others
Mortality Risk:
Low :<-1
Intermediate : -1 --+1
High :>+1
Summeries
Nutritional assessment:
The first step of medical nutrition Therapy
Begin with patient and family
The patient medical record: Communication
among health care team members
Porpuse , Identify:
Nutrient deficiency
Nutritional status
Nutrient requirement
Nutritional relative diseases
Evaluation and monitary medical nutrition
intervention
Refferences

Gibson RS. Principles of Nutritional


Assessment. Oxpord University Press,
1990
Jeejeebhoy KN. Current therapy in
nutrition. BC Decker Inc. Toronto, 1988
Mahan LK, Arlin MT. Krauses : Food,
Nutrition and Diet Therapy. 8th ed. WB
Sounders Co. Philadelphia, 1992.
Williams SR, Schlenker ED. Essensials of
Nutrition & Diet Therapy. 8th ed. Mosby,
2003.