Nutritional Assessment Lecture PDF

Nutritional Assessment Lecture: 2nd &3rd Anthropometric methods for nutritional Assessment for adults Assistant Prof. Dr. Emad Ali AL-Shameri Consultant of Nutrition & Dietetics [email protected]  Course Elements...

Nutritional Assessment Lecture: 2nd &3rd Anthropometric methods for nutritional Assessment for adults Assistant Prof. Dr. Emad Ali AL-Shameri Consultant of Nutrition & Dietetics [email protected]  Course Elements ▪ Importance & Definitions ▪ Advantages & disadvantages ▪ Uses ▪ Anthropometric methods Body composition measurements ▪ Evaluation of anthropometric indices ▪ Classification systems to identify individuals at risk of malnutrition 2  Anthropometric measurements ▪ It is the third aspect in the assessment of the nutritional status. ▪ It is the measurement of body weight and proportions. Anthropometric methods ▪ It includes evaluation of the body composition for determination of: 1. Genetic. 2. Endocrine. 3. Nutritional. 4. Disease related problems. 3  Anthropometric measurements ▪ It is also used to evaluate both under and over nutrition. ▪ The measured values reflect the current nutritional status. ▪ Evaluation of body composition yields information about Anthropometric methods the: 1. amount and distribution of fats. 2. proteins (both muscle and visceral). 3. structural compartments and water. 4  Importance & Definitions Why Study Body Composition? ▪ Refers to the relative amounts of the different compounds in the body. Anthropometric methods Why Study Body Composition? ▪ Over weight vs. Over fat vs. Obesity. ▪ Risk for various diseases ▪ Monitor change from an intervention. ▪ Some job requirements involve body composition standards. ▪ Athletic/sport limit factor 5  Body Composition Matiegka Method 4 components: 1. Skeletal mass (bones). 2. Fat body mass (fat). Anthropometric methods 3. Muscle mass (muscles). 4. Other. 6  Width dimensions (diameter) Biepicondylar humerus. Bistyloideus. Biepicondylar femur. Bimalleolar. Anthropometric methods 7 Anthropometric methods Width dimensions (diameter) 8  GIRTH relax arm. flexed arm. forearm girth. thigh girth. Anthropometric methods calf girth. 9  Anthropometric methods 10  Anthropometric methods 11  MEN WOMEN Skeletal mass: 17% 16% Anthropometric methods Muscle mass: 46% 41% Fat body mass: 14% 22% Other: 23% 21% 12  Different methods assessment ▪ Different methods for assessing the body composition are: 1. Laboratory methods Hydrodensitometry. Anthropometric methods 2. Imaging techniques Dual energy X-ray Absorptionmetry (DEXA). Computed Tomography (CT). Magnetic Resonance Imaging (MRI). 3. Elemental analysis techniques. Total body potassium counting. Isotope dilution techniques. 13  1. Laboratory Methods ▪ Hydro densitometry or under water weighing: ▪ The subject exhales maximally and is weighed while submerged in water, and pulmonary residual volume is Anthropometric methods measured and deducted from the volume of water displaced. a. Body volume (BV), b. body weight (BWt), c. under water weight (UWW), d. density (D), BV = BWt - UWW D= BWt ÷ BV 14  2. Imaging Techniques ▪ Dual-Energy X-ray Absorptiometry (DEXA): ▪ Two x-ray beams with differing energies are passed through Anthropometric methods the body. ▪ It is used to estimate bone mineral density, fat mass, and lean body mass which are quite accurate and precise. 15  2. Imaging Techniques ▪ Computed tomography (CT) ▪ Radiographic and computer analysis is used to Anthropometric methods determine the structure of internal organs. ▪ Provides a very accurate indication of regional body composition, e.g., visceral and subcutaneous abdominal fat. 16  2. Imaging Techniques ▪ Magnetic resonance imaging (MRI): ▪ A powerful magnet is used to alter motion of atoms within the body; Anthropometric methods from these changes, computerized images of internal body tissues are produced. ▪ Provides an indication of regional body composition. 17  2. Imaging Techniques ▪ Strengths: 1. Accurate. 2. Allows for measurement of specific body fat compartments, Anthropometric methods such as abdominal fat and subcutaneous fat. ▪ Limitations: 1. Equipment is extremely expensive. 2. CT scans cannot be used with pregnant women or children, due to the high amounts of ionizing radiation. 3. Some MRI and CT scanners may not be able to accommodate individuals with a BMI of 35 or higher. 18  3. Elemental Analysis Techniques ▪ Total body potassium counting: ▪ Potassium is present in fat free tissues more than 90% and its concentration is assumed to be relatively constant but slightly different in males and females. Anthropometric methods ▪ Measurements are made with a special counters that is fitted with multiple gamma-ray detectors interfaced with a computer. ▪ The known proportion of natural potassium occurs as a radioactive isotope, its decay produces gamma-emissions detectable using whole body counters. ▪ Whole body counters are rarely available, expensive and affected by variations in body shape and dimensions and environmental contamination. 19  3. Elemental Analysis Techniques ▪ Isotope dilution techniques: ▪ Two fluid samples (blood, saliva, or urine) are collected: one just before administration of a radioactive or stable (nonradioactive) isotope, to determine the natural Anthropometric methods background levels, and the second sample after waiting a sufficient amount of time for the isotope to equilibrate within the body. ▪ Typically the subject drinks water labeled with deuterium (2H) or 18O to label the body water pool; urine samples are collected for isotope analysis. 20  3. Elemental Analysis Techniques ▪ Isotope dilution techniques: ▪ Total body water is calculated, and from this fat mass and fat free mass (FFM) are estimated. Anthropometric methods ▪ Deuterium H2 dilution is a technique of choice as it is safe stable isotope occurs naturally in the water. ▪ Oxygen 18 is also a stable isotope and potentially more accurate for total body water (TBW) estimation. ▪ It is not used in liver and kidney diseases. 21  Types of Anthropometric measurement for adults ▪ Five general types of Anthropometric measurement for adults are: 1. Weight. Anthropometric methods 2. Height. 3. Circumferences. 4. Skin folds. 5. Others (BMI & BIA). 22  1. Weight a. weight is the best indication of protein, calorie, over and under nutrition. b. Rate of weight change has a prognostic Anthropometric methods indication of the body’s ability to survive stress. c. The easiest way to measure weight is by a portable spring balance or an electronic balance. d. It is recorded without shoes and with minimal clothing's. e. The scale should be calibrated to zero before weighing. 23  1. Weight ▪ The rate of change in weight can be calculated by comparing the present weight with the usual or the pre-illness weight. 1. Present IBW= Actual weight / standard weight x 100. Anthropometric methods 2. Present UBW= Actual weight / UBW X 100. 3. Percent weight change= Usual weight - Actual weight / usual weight X 100. 4. Recent weight change= (UBW- current weight) X 100 / UBW. 24  1. Weight ▪ Interpretation of IBW: 1. ≥ 200% Morbidly obese. 2. ≥ 130% Obese. Anthropometric methods 3. 110-120% Overweight. 4. 80-90% Mild malnutrition. 5. 70-79% Moderate malnutrition. 6. < 69% Severe malnutrition. 25  2. Height ▪ Height or stature is the distance from the crown of the head to the soles of the feet. Anthropometric methods ▪ The subject stands erect and bare footed on a stadiometer with a movable head piece is leveled with skull vault and height is recorded to the nearest 0.1 cm. ▪ Height decreases with age. ▪ When a patient is unable to stand due to excessive spinal curvature, the knee height is an appropriate alternative parameter. 26  2. Height ▪ Knee height: ▪ A large sliding caliper is used to measure the knee height, on the Anthropometric methods left side, when subject lies supine with the knee and ankle flexed to 90 degree. ▪ The fixed blade of the caliper is placed under the heel and other blade on the anterior surface of the thigh just proximal to the patella. 27  2. Height ▪ Knee height: ▪ The shaft of the caliper is held parallel to the shaft of the tibia and pressure is applied to compress the tissue. The Anthropometric methods two measurements are recorded nearest of 0.1cm. ▪ The average of two measurements is connected to full stature using equations: Males: 64.19 - (0.04 X age) + (2.02 + knee height). Females: 84.88 - (0.24 X age) + (1.83 X knee height). 28  2. Height ▪ Arm span method: ▪ A non-flexible tape is used to measure the length from the tip of one middle Anthropometric methods finger to the middle finger of the other hand, passing over the clavicles, while the patient is lying in supine position with the arms extended. 29  2. Height ▪ Ulna length: ▪ The measurement is taken at the left forearm with a tape measure. With Anthropometric methods the arm bent, the distance between the tip of the elbow (olecranon) and the wrist (styloid process) is measured. ▪ This measurement is checked in the table below to find the height. 30 Measured ulna Men ≥ 65 years Men < 65 Women ≥ 65 Women < 65 length years years years 18.5 1.46 1.45 1.47 1.40 19 1.48 1.46 1.48 1.42 19.5 1.49 1.48 1.50 1.52 20 1.51 1.49 1.51 1.44 20.5 1.53 1.51 1.52 1.47 21 1.55 1.52 1.54 1.48 21.5 1.57 1.54 1.55 1.50 22 1.58 1.56 1.56 1.52 22.5 1.60 1.57 1.58 1.53 23 1.62 1.59 1.59 1.55 23.5 1.64 1.60 1.61 1.56 24 1.66 1.62 1.62 1.58 24.5 1.67 1.63 1.63 1.60 31 25 1.69 1.65 1.65 1.61 Measured ulna Men >= 65 Men < 65 Women >= 65 Women < 65 length years years years years 25.5 1.71 1.67 1.66 1.63 26 1.73 1.68 1.88 1.65 26.5 1.75 1.70 1.69 1.66 27 1.76 1.71 1.70 1.68 27.5 1.78 1.73 1.72 1.70 28 1.80 1.75 1.73 1.71 28.5 1.82 1.76 1.75 1.73 29 1.84 1.78 1.76 1.75 29.5 1.85 1.79 1.77 1.76 30 1.87 1.81 1.79 1.78 30.5 1.89 1.82 1.80 1.81 31 1.91 1.84 1.81 1.81 31.5 1.93 1.86 1.83 1.83 32 32 1.94 1.87 1.84 1.84  3. Circumferences ▪ Waist circumference predicts mortality better than any other anthropometric measurement. Anthropometric methods ▪ Waist circumference and waist-hip ratio are measures of risk of obesity-associated morbidity. ▪ The WHO cut-offs for waist circumference. Increased Substantially increased Men ≥ 94 cm ≥102 cm Women ≥80 cm ≥88 cm 33  3. Circumferences ▪ Hip circumference ▪ It is measured at the point of greatest circumference around hips and buttocks to the Anthropometric methods nearest 0.5 cm. ▪ The subject should be standing and the measurer should squat beside him. ▪ Both measurement should be taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue 34  3. Circumferences ▪ Waist/Hip ratio(WHR) ▪ Waist circumference is measured at the level of the umbilicus to the nearest 0.5 cm. ▪ The subject stands erect with relaxed abdominal muscles, Anthropometric methods arms at the side, and feet together. ▪ The measurement should be taken at the end of a normal expiration. ▪ A WHR below these cut-off levels considered low risk 35  3. Circumferences ▪ Interpretation of Waist/Hip Ratio (WHR) ▪ High risk WHR = Anthropometric methods > 0.80 for females and > 0.95 for males. i.e. waist measurement > 80% of hip measurement for women and. > 95% for men ---indicates central obesity and is considered high risk for diabetes and cardiovascular disorders. 36  3. Circumferences ▪ Mid Upper Arm Circumference (MUAC) ▪ Measured half-way between the Anthropometric methods acromion process of the scapula and the tip of the elbow (ulnar) with the arm hanging vertically and forearm supinated. 37  4. Skin folds ▪ The skin fold measurements are used to commonly estimate the energy reserves in Anthropometric methods the subcutaneous fat. ▪ Herpendis caliper is most commonly used. they measure the double thickness of skin with the fat layer in between. ▪ used in combination to obtain body fat. 38  4. Skin folds 4. Skin folds measurements: 1. Triceps skin fold. 2. Biceps skin fold. Anthropometric methods 3. Sub scapular skin fold. 4. Suprailiac skin fold. 5. Forearm. 6. Chest2. 7. Midthigh. 8. Abdomen. 9. Medial calf. 10. Supraspinal. 39  4. Skin folds 4. Skin folds: a. Triceps skin fold: is measured at the mid point of back up of upper left arm, Anthropometric methods between the acromion process and the tip of olecranon. ▪ It is frequently used because it represents the whole of the subcutaneous fat layer. https://www.youtube.com/watch?v=pARYB0XnluY b. Biceps skin fold: is measured as the thickness of the vertical fold on the front of the upper left arm above the center of the cubital fossa, as the same level as the triceps skin fold. 40  4. Skin folds 4. Skin folds: c. Sub scapular skin fold: is measured just below and lateral to the inferior angle of Anthropometric methods the scapula, with the shoulder and the arm relaxed. https://www.youtube.com/watch?v=PAaPTA_M41s https://www.youtube.com/watch?v=8iAyC-pEwJ4 https://www.youtube.com/watch?v=PAaPTA_M41s d. Suprailiac skin fold: is measured in the midaxillary line immediately superior to the iliac crest. 41  4. Skin folds ▪ Limitations of skin-fold measurements: 1. Skin fold compressibility differs with each individual, so there may be discrepancies between actual fat layer and Anthropometric methods skin fold. 2. It does not take into account the non-subcutaneous fat in places throughout the body. 3. Individual differences occur due to: a. sex. b. weight loss with aging and, c. in athletes. 42  4. Skin folds ▪ Limitations of skin fold measurements: 4. Its validity of estimating body composition in muscular and very obese subjects is questionable. Anthropometric methods 5. Skin fold measurements are useful for assessing long-term changes in subcutaneous tissues. 6. Fluid accumulation in conditions like congestive heart failure, liver, kidney diseases makes interpretations difficult. 43  5. Others (BMI & BIA). ▪ Body Mass Index (BMI): ▪ The international standard for assessing body size in adults is the body mass index (BMI). Anthropometric methods ▪ It describes the degree of body fatness. ▪ The ratio of mass to height2. ▪ BMI = body mass (kg) / body height (m)2. for example: BMI = 80 (kg) / 1.72 (m) = 27.68 kg/m2. 44  5. Others (BMI & BIA). ▪ Body Mass Index (BMI): ▪ < 18.5 = Underweight. Anthropometric methods ▪ 18.5-24.9 = Normal Weight. ▪ 25-29.9 = Overweight. ▪ 30-34.9 = Moderate Obese (Class 1). ▪ 35-39.9 = Severely Obese (Class 2). ▪ ≥40 = Extreme Obesity (Class 3). ▪ A BMI > 30 is associated with greater prevalence of mortality from heart disease, cancer, and diabetes. 45 Anthropometric methods 5. Others (BMI & BIA). 46  5. Others (BMI & BIA). ▪ Bio Electrical Impedance Analysis (BIA): Device: 1. Omron. Anthropometric methods 2. Tanita. 3. Body stat. 4. In-Body. 47  5. Others (BMI & BIA). ▪ Bio Electrical Impedance Analysis (BIA): ▪ BIA requires passage of small electrical current, undetectable to the individual, Anthropometric methods between two electrodes placed on the body. ▪ Tissues rich in water (muscle and other lean tissues) are good electrical conductors, whereas fat is a poor conductor. ▪ It measures body water and estimates fat content. 48  5. Others (BMI & BIA). ▪ Bio Electrical Impedance Analysis (BIA): ▪ It is a quick, noninvasive, and relatively inexpensive way to assess body composition. Anthropometric methods ▪ Serial measures can track changes in body composition. ▪ Single-frequency (50 kHz) bioelectric impedance analysis (BIA) has been evaluated for its ability to: a. estimate lean body mass. b. total body water. c. extracellular fluid and, d. body cell mass. 49  5. Others (BMI & BIA). ▪ Advantages: 1. Relatively inexpensive, 2. Portable equipment; Anthropometric methods 3. Easy and fast to perform; 4. Reproducible; 5. Can measure intracellular and extracellular water compartments; 6. Segmental analysis allows estimation of muscle and fluid in segments of the body, e.g., trunk or extremity. 50  5. Others (BMI & BIA). ▪ Disadvantages: 1. Accuracy is affected by numerous factors that may be hard to control: changes in Anthropometric methods a. hydration. b. electrolyte concentrations and skin temperature (fever or cold exposure). c. recent eating, drinking, exercise, and position changes; 2. inaccurate in cases of limb amputation or regional alterations of skeletal muscle, e.g., muscular dystrophy 51  Advantages of Anthropometry 1. Simple, non-invasive. 2. Equipment is inexpensive, portable. 3. Relatively unskilled personnel can perform measurements. 4. Methods are reproducible. Anthropometric methods 5. Measures long term nutritional history. 6. Quickly identifies mild to moderate malnutrition. 7. Measures many variable of nutritional significance like: a. Height. b. Weight. c. skin fold thickness. d. head circumference waist. e. hip ratio and BMI. 52  Disadvantages of Anthropometry 1. Relatively insensitive to short term nutritional status. 2. Cannot identify specific nutrient deficiencies. 3. Measurements: e.g.. Skin-folds difficult to carry out in obese people. Anthropometric methods 4. Ethnic differences in fat deposition. 5. State of hydration. 6. Position of the subjects. 7. Non-availability of the normal and pre-illness measurements 53  Anthropometric Methods Thank you Anthropometric Methods Any Questions 54