Nutritional Assessment Part 2 PDF

Nutritional Assessment Part 2 NUTR 344 – WINTER 2024 Required readings Nelms textbook: Chapter 3 and related Appendices D-G Chapter 2: Overview of the Nutrition Care Process, p.25-30 Review article on REE equations by Frankenfield et al. 2005 Additional reference for consultation: Gibson, R.S. P...

Nutritional Assessment Part 2 NUTR 344 – WINTER 2024 Required readings Nelms textbook: Chapter 3 and related Appendices D-G Chapter 2: Overview of the Nutrition Care Process, p.25-30 Review article on REE equations by Frankenfield et al. 2005 Additional reference for consultation: Gibson, R.S. Principles of Nutritional Assessment, 2nd edition, Oxford University Press, 2005. Dietary Assessment Dietary Assessment Methods 24-hour recall Usual daily typical intake pattern Food record or diary Food frequency questionnaire Direct observation Technology-based software/programs (photos, input data) Choice of method depends on: ◦ Individual vs. group ◦ Nutrients of interest ◦ Goal: quick estimation vs. precise evaluation 24-hour recall: don’t used it in practice that much ask client about what they ate/drank in last 24 hours or yesterday • Used quite often in research, repeated over time, used with populations • Multiple ones required to assess usual intake (≥3) less accurate if only 1 person or only 1 time • Advantages: - Quick and inexpensive - Can get good detail because specific to 24 hours. - Low patient burden. - Can do a "multiple pass" and cue client to help them remember • Disadvantages: - Memory dependent. May forget to report or may underreport. - Overestimation/underestimation. One 24 hour may not be representative. - High inter-interviewer variability Usual typical daily food intake pattern •Ask client what they eat in a typical day. •Advantages: oLow burden on client oRelatively quick. oCan obtain a usual daily intake pattern to interpret trends. •Disadvantages: oIntake pattern can be very variable for some clients, portion sizes may vary. oMay be difficult to get portion sizes or description. oUnder-reporting is common.bc gives you the answer they think you want to hear Food Record or Diary • Recorded or weighed for a given time period (3-7 days) • Advantages: - Greater precision than 24-h recall, if recorded well - Not memory dependant (unless forget to record!) - Considered actual intake for several days • Disadvantages: - Time consuming - May not reflect “normal” eating patterns, may change behavior - Pt must be literate and motivated (writing, weighing, time consuming) Food frequency questionnaire • Survey of intake over specified time • Includes food list, consumption frequency • Advantages: - Can examine specific nutrients - Can be used in large studies (epidemiological) - Considered usual intake • Disadvantages : - Qualitative information and less accurate - Memory dependant - Difficult food intake may be variable and hard to quantify - Pt must be literate and motivated (writing, time consuming) Direct Observation • Used in controlled setting • Does not represent usual intake • Advantages: - More precise - Not memory or literacy dependent - Patient unaware of assessment • Disadvantages : - High staff burden - May be intrusive if you know somebody is watching you eat —> awkward, won’t eat like normally Dietary Assessment – Technology-based methods  Web-based: Automated Self-Administered 24-h food recall (ASA24-Canada) https://epi.grants.cancer.gov/asa24/  Free to use but more for research than clinical purposes  Mobile applications: caution, verify source of data  Image-based mobile application: Keenoa (https://keenoa.com)  McGill Start-up,  Based on Canadian Nutrient File and more national databases  Monthly fees for dietitians, free for clients Energy, protein, and fluid requirements Components of Total Energy Expenditure Injury/Stress TEF (<10%) % of TEE Physical Activity (20-30%) Injury/Stress TEF Physical Activity REE or BMR REE or BMR (60-70%) Example of moderately active individual Example of hospitalized patient Indirect Calorimetry "Gold standard" For Energy Measuring REE: Indirect Calorimetry  Measures the quantity of oxygen consumed (VO2) and CO2 produced (VCO2) from substrate utilisation and energy related processes  Respiratory quotient (RQ): VCO2 / VO2  From this, heat (i.e. energy) production is calculated from the Weir equation: REE (kcal/d) = 1.44 x (3.9 x VO2 + 1.1 x VCO2) When do we need to know the estimated energy requirements? • Most important reasons: If a patient is critically ill, acutely ill, not able to eat properly, and at risk of malnutrition. •Can compare their actual intake to their estimated energy needs. •Indirect calorimetry would be best but if not available, then use a predictive energy equation. if no intensive care, usually no indirect calorimetry Over time, don’t always need to calculate it, we can just look at their weight if someone is critically ill: need to calculate it •Which predictive energy equation is best? if no indirect calorimetry PEN: Practice-based Evidence Nutrition PEN says Harris-Benedict or Mifflin St-Jeor are best, within 10% of REE can be a lot more than 10% depending on gender, age, BMI, race… Overweight and obesity(from PEN) For obesity, there are varying opinions. PEN says Harris-Benedict is best. Nelms textbook, Chapt 3, pg 68, says Mifflin St-Jeor for Overweight or Obese " For the non-acutely ill overweight or obese individual, it is recommended to use the Mifflin St-Jeor equation." From the Academy of Nutrition and Dietetics (AND) (USA) and the Evidence Analysis Library (EAL) Mifflin St-Jeor is recommended for the majority of disease conditions. From 2005 Frankenfield article "Of these equations, the Mifflin-St Jeor equation was the most reliable, predicting RMR within 10% of measured in more nonobese and obese individuals than any other equation, and it also had the narrowest error range." "Older adults and US-residing ethnic minorities were underrepresented both in the development of predictive equations and in validation studies." Mifflin-St Jeor (1990) Men: REE (kcal/d)= (9.99 x wt) + (6.25 x ht)- (4.92 x age) +5 Women: REE (kcal/d)= (9.99 x wt) + (6.25 x ht)- (4.92 x age) – 161 Wt = Weight in kg Ht = Height in cm Age = Age in years Can be used in non-obese and obese subjects. In this course, we will recommend MSJ for non-acutely ill obesity (Nelms)  Use current (actual) body weight Harris-Benedict (1919) Men: REE (kcal/d) = 66 + (13.8 x wt) + (5 x ht) - (6.8 x age) Women: REE (kcal/d) = 655 + (9.6 x wt) + (1.9 x ht) - (4.7 x age) Wt = Weight in kg Ht = Height in cm Age = Age in years Tends to overestimate REE by 5-15% - Except in males >65 where it underestimates REE Harris JA, Benedict FG. 1919. A Biometric Study of Basal Metabolism in Man. Publ 279 Estimating energy requirements Predictive energy equations to estimate REE: (also table 3.15, Nelms) Harris-Benedict Mifflin-St. Jeor Based on height, weight, age and sex FAO/WHO TEE = REE x Activity Factor x Stress Factor FAO/WHO Equations (taken from Nelms textbook, chap. 3 page 69) not used that much in practice Men: 18-30 y REE = (15.4 X wt) - (27 x height) + 717 30-60 y REE = (11.3 X wt) + (16 x height) + 901 >60 y REE = (8.8 X wt) + (1128 X ht) - 1071 REE in kcal/day wt = Weight in kg ht = Height in m FAO/WHO Equations (taken from Nelms textbook, chap 3 pg. 69) Women: 18-30 y REE = (13.3 X wt) + 334 x height) + 35 30-60 y REE = (8.7 X wt) + - (25 x height) + 865 >60 y REE = (9.2 X wt) + (637 X ht) - 302 REE in kcal/day wt = Weight in kg ht = Height in m FAO/WHO. 1985. Energy and Protein requirements. Geneva: WHO; Technical Report Series 724 Physical Activity for hospitalized or long term care Description of activities PAL Chair or bed bound 1.2 x REE Seated work w/ little movement; little or no leisure activity 1.3-1.5 x REE Stress factors Description Stress factor (SF) Elective surgery 1.0-1.1 x REE Multiple trauma 1.4 x REE Severe infection 1.2-1.6 x REE Peritonitis 1.05-1.25 x REE Multiple bone fractures 1.1-1.3 x REE Infection with trauma 1.3-1.55 x REE Stress factors Description Stress factor (SF) Sepsis 1.2 -1.4 x REE Closed head injury 1.3 x REE Cancer 1.1-1.5 x REE Burns 1.5-2.1 x REE Fever 1.2 x REE per 1oC >37oC Is there a risk of overfeeding? In a critical illness, there could be some risk of overfeeding. Use stress factors with caution. "Overfeeding may be much more detrimental than underestimation of needs" in critical illness. Stress factors need to be used with caution —> underfeeding might be better when critically ill than overfeeding (too much stress for your body) From Nelms, Chap 3, pg 69 " Based on expert consensus, in the absence of indirect calorimetry, we suggest that a published predictive equation or a simplistic weight based equation (25 – 30 kcal/kg/day) be used to determine energy requirements." Additionally, it is recommended that the patient be followed closely and his/her energy requirements be reassessed more than weekly. Can reassess by monitoring weight. FAO/WHO Obesity (from Nelms Chap 3, pg 69 Obesity: BEE for BMI 30 – 50: 11 –14 kcal/kg actual body weight BEE for BMI > 50: 22 – 25 kcal/kg IBW Simple kcal/kg "rule of thumb", quick calculation used a lot bc simple calculation, only uses the weight (no gender, no height, no activity factor) complex equation: not that accurate so a lot of ppl go with this one bc faster and know it’s not really accurate so you expect that Based on FAO/WHO equation. 25-35 kcal/kg Common usage: 25 kcal/kg for low level of activity or overweight or poor appetite 30 kcal/kg for usual moderate activity, non-obese 35 kcal/kg for higher active or higher needs or underweight For obesity: Use a weight for a healthy BMI = 25 (upper range) for adults under 65 y.o, and 29 if 65 y.o. or older, with 25 to 30 kcal/kg range. Some practitioners may choose to use a realistic BMI of 29 especially if actual BMI is > than 35. Simple kcal/kg contd. Very elderly in long term care 2023 DRI Update: Energy Institute of Medicine (IOM), National Academy of Sciences (NAS) Not hospitalized Weight in kg. Height in cm. Activity is already part of equation. 2023 DRI Update: Energy Institute of Medicine (IOM), NAS Range of Values for Energy Given that even the "best" predictive energy equation(s) are not very accurate for an individual on a specific day, under most circumstances it makes sense to give a range of reasonable values. Example: 1900 - 2100 kcal per day. If uncertain, some practitioners may calculate energy needs using two different methods and compare or average the results. Monitor weight. Protein requirements For healthy individuals: FAO/WHO: 0.75 g/kg body wt/day DRIs: EAR= 0.66 g/kg/d RDA=0.8 g/kg/d BUT, consensus for revising upward (PROT-AGE Study Group, J Am Med Dir Assoc 2014) Healthy adults: 1.0 g/kg/day Older adults (≥65 y): 1.0-1.2 g/kg/day We used these recommendations in this course Protein requirements will vary depending on physiological or disease status: 1.2 - 2.0 g/kg/d What if the client has a very low weight/BMI or very high weight/BMI? No clear answer. Actual weight is commonly used. Can adjust by using lower or higher g/kg. Is there any risk/benefit to over- or under- estimating? Being very underweight or very obese creates greater inaccuracy. Use professional judgement. Examples : protein calculations BMI very low or very high. Consider age. Example 1, Method 1: BMI = 14. Client is 96 y.o. Decide to use a higher g/kg. 1.2 - 1.5 g/kg x actual weight. Example 1, Method 2: BMI = 14. Client is 96 y.o. Decide to calculate using a weight that would give a more healthy or ideal BMI. Use 1.0 - 1.2 g/kg x a weight that would be better (example that would give a BMI of 20). Example 2, Method 1: BMI = 37. Client is 65 y.o. Use a lower g/kg like 0.8 x actual weight. Example 2, Method 2: BMI = 37. Use a weight that would give a healthier BMI for the age. If the client is 65, use a weight that would give a BMI of 29. Use that weight x 1.0 - 1.2 g /kg. Fluid requirements • Several methods exist • WEIGHT - 100 ml/kg body weight for 1st 10 kg - 50 ml/kg body weight for next 10 kg - 20 ml per kg body weight for each kg above 20 kg - EXAMPLE: 70 kg male • (100 X 10) + (50 X10) + (20 X 50) = 2500 ml Fluid requirements • WEIGHT & AGE - 16-30 years, active: 40 ml/kg body weight - 20-55 years: 35 ml/kg body weight - 55-75 years: 30 ml/kg body weight - >75 years: 25 ml/kg body weight - EXAMPLE: 70 kg, male, 40 y.o. • 35 X 70 = 2450 ml Fluid requirements Based on energy requirements: 1 mL/kcal Example: 70 kg, male, 40 y, 2500 kcal = 1 x 2500 = 2500 mL (2.5 L) Based on fluid balance: urine output + 500 mL/day Age-related minimum: For the elderly, we may suggest not less than 1500 ml (unless medical reason to restrict fluids). Fluids are liquids at body temperature Fluid requirements change with various disease conditions Dehydration Symptoms • Thirst (1-2% of body water lost) • Dark urine, increased urine specific gravity • Decreased skin turgor • Dry mouth, lips • Tachycardia • Headache • Lowered body temperature • Restlessness, confusion • Rapid weight loss (1 kg = 470 mL) • Increased Na, albumin, BUN, creatinine, Hb, Hct Overhydration Symptoms • Increased blood pressure • Decreased pulse rate • Edema • Decreased Na, K, albumin, BUN, creatinine, Hb, Hct • Rapid weight gain Special considerations for older adults Nutrients of concern: Energy : reduced due to reduced FFM and activity = low appetite Protein: 1-1.2 g/kg/day, may be higher if other conditions present Calcium: decreased Ca absorption with age (DRI=1200 mg >50 y) Vitamin D: less efficient synthesis by skin, kidney conversion, and exposure Vitamin B12: less efficient absorption Fluids: decreased sense of thirst, presence of other diseases (dehydration leads to confusion) Special considerations for older adults Dental status, capacity for mastication Swallow function, dysphagia GI function Medical diagnosis, multiple? Polypharmacy Social environment, independent living Cognitive function Functional ability  see Box 3.4 in Nelms Malnutrition screening and diagnosis Prevalence of malnutrition 15 – 80%* community hospitals long-term care *according to population studied, criteria & cutoffs Mueller C et al. ASPEN Board of Directors. J Parenter Enteral Nutr 35 :16-24, 2011 Prevalence of malnutrition in Canada Canadian Malnutrition Task Force: ◦ Prospective study, 18 acute-care hospitals, 1022 patients ◦ excluded: <18 y, ICU, obstetrics, palliative, psychiatric patients, day centres Results   424 patients (163 surgical) hospitalization ≥7 days: 51% malnourished: 37% moderate, 14% severe During stay: 20% deteriorated, 17% improved www.nutritioncareincanada.ca Allard J, Keller H et al. Br J Nutr 114 (10), 2015. Elements of screening Current condition ?  BMI ◦ BMI 18.5-20 kg/m2 = risk; <18.5 kg/m2 = ↓ lean mass Stable weight or involontary weight loss ? ◦ Severe: >5% in 1 month or 10-15% in 6 months ◦ Moderate: >5% in 3 months Prognosis/Will condition deteriorate? ↓ food intake ◦ Risk of malnutrition ESPEN: European Society Clinical Nutrition Canadian Nutrition Screening Tool (CNST) Validated against SGA Other Screening Tools MUST: Malnutrition Universal Screening Tool ◦ (http://www.bapen.org.uk) MNA: Mini Nutritional Assessment (Long and Short versions, see next) Malnutrition diagnosis Global Leadership Initiative on Malnutrition Grading severity of malnutrition Resources Canadian Malnutrition Task Force https://nutritioncareincanada.ca ASPEN Guidelines https://www.nutritioncare.org/guidelines_and_cli nical_resources/Malnutrition_Solution_Center/