Clinical Nutrition & Nutritional Assessment PDF

CLINICAL NUTRITION and NUTRITIONAL ASSESSMENT Dr. DENİZ ERTEM OBJECTIVES OF THE LECTURE  Introduction  Nutritional sources ◼ Carbohydrates, proteins lipids, vitamins, trace elements  Nutritional requirements (adults, children)  Assessment and classification of malnut...

CLINICAL NUTRITION and NUTRITIONAL ASSESSMENT Dr. DENİZ ERTEM OBJECTIVES OF THE LECTURE  Introduction  Nutritional sources ◼ Carbohydrates, proteins lipids, vitamins, trace elements  Nutritional requirements (adults, children)  Assessment and classification of malnutrition  Methods for nutritional assessment  HUMAN NUTRITION A healthy diet provides ◼ balanced nutrients satisfies metabolic needs of the body without excess or shortage  Malnutrition = Bad nourishment  This term concerns not enough as well as too much food consumption, consuming wrong types of food, or inability to use nutrients properly to maintain health.  Malnutrition is one the most common causes of death in children under 5 yr of age.  Energy needs depend on: ◼ Basal metabolism ◼ Rate of growth ◼ Physical activity ◼ Onset of puberty ◼ Presence of chronic disease Basal Metabolic Rate is closely related to the Resting Energy Expenditure It is the energy expended by humans at rest, namely during post absorptive state in a neutrally temperate environment)  CALCULATION OF REE (WHO, SCHOFIELD, HARRIS BENEDICT EQUATIONS)  WHO EQUATION 1-3 AGE (BOYS) REE (kcal/d)= 60.9 x WEIGHT – 54 Resting energy expenditure increases in stressfull conditions 3-10 --------- REE (kcal/d)= 22.7 x WEIGHT – 495 ◼ MILD STRESS (minor surgery, hospitalization) 10-18 -------- REE (kcal/d)= 17.5 x WEIGHT – 651  REE x 1.3 18-30 -------- REE (kcal/d)= 15.3 x WEIGHT – 679 ◼ MODERATE STRESS (trauma, sepsis, cancer, major surgery) 1-3 AGE (GIRLS) REE (kcal/d)= 61 x WEIGHT – 51  REE x 1.5 3-10 --------- REE (kcal/d)= 22.5 x WEIGHT – 499 ◼ SEVERE STRESS (also for catch-up growth) 10-18 -------- REE (kcal/d)= 12.2 x WEIGHT – 746  REE x 1.7 18-30 -------- REE (kcal/d)= 14.7 x WEIGHT - 496 Harris-Benedict Equations (calories/day): Male: 665 + 13.75 x weight + (5.0 x height) - (6.78 x age) Female: 665 + 9.56 x weight) + (1.85 x height) - (4.68 x age) Carbohydrates --- main source of energy  Provide --- 4 kcals/ gm  Carbohydrates are also essential for synthesis of certain non-essential amino acids  Stored in the form glycogen  If stores depleted --- protein and dietary/endogenous glycerol used to maintain glucose homeostasis Proteins --- complex organic nitrogenous compounds Not utilized for energy productıon Proteins are conserved if enough non-nitrogen calories supplied by CHO and lipids Fats provide 20-%40 of total energy intake  Provide high amount of energy (1 gm fat --- 9 kcal)  Fats serve as vehicles for fat-soluble vitamins (A,D,E,K) Vitamins and trace elements  Essential nutrients  Required in a very small amounts (micronutrients)  Vitamins are divided into two groups: ◼ fat soluble vitamins- A, D, E and K ◼ water soluble vitamins: vitamins of the B-group and vitamin C NORMAL GROWTH PATTERN IN CHILDREN  Dramatic physical changes occur in the 1st yr of life ◼ Birth weight triples ◼ Birth height increases by 50% ◼ 0-4 months of age ---- 30 mg/d ◼ 5-8 months of age ---- 20 gm/d ◼ 9-12 mo of age ------- 15 gm/d  2 yr ---- puberty ◼ Average weight gain --- 2-3 kg/year ◼ Average height gain --- 6-8 cm/year ◼ Fine, gross motor, social and cognitive development predominate after the 1 st year  ENERGY REQUIREMENT Recommendation Dietary Allowances (RDA) based on healthy-active children Age Kcal/kg 0-6 months 110 6-12 months 100-110 1-3 years 100 4-6 years 90 7-10 years 70 11-14 years males 55 11-14 years females 50 ADULTS MAINTENANCE --- 30-35 kcal/kg REBUILD --- 35-40 kcal/kg  DAILY PROTEIN REQUIREMENT (RDA) Age Gram/kg/day ❑ To prevent nitrogen loss 0-6 months 2.2 from muscles and 6-12 months 1.6 support tissue and 1-3 yrs 1.2 muscle build-up 4-6 yrs 1.1 ❑ Excess protein supply: 7-10 yrs 1 ❑ BUN , kreatinine 11-14 yr male 1 ❑ calcium excreation 11-14 yr 1 female  BEDSIDE CALCULATION OF DAILY ENERGY REQUIREMENT CHILDREN  FIRST 10 KG ---- each kg x 100 kcal  SECOND 10 KG --- each kg x 50 kcal  Each kg above 20 --- each kg x 20 kcal 23 KG CHILD 10X100 =1000 10X50 =500 2X20 =40 TOTAL=1540 kcal/day  PROTEIN ENERGY MALNUTRITION  The term PEM was first adopted by WHO in 1976  Highly prevalent in developing countries in children younger than 5 yr  In children < 5 yr of age ---- 300.000 deaths/year  More common in developing countries  In 2015, expected worldwide prevalence 17-18%  In USA, it is less than 1%  In Saharan Africa it is 30%  Primary (inadequate intake of E and protein)  Common in developing countries  Secondary (common in developed countries)  Usually secondary to malabsorption / chronic diseases CONSEQUENCES OF CHRONIC MALNUTRITION Impaired growth & development Increased susceptibility to infections Poor wound healing Impaired neurological and cognitive development Undernutrition / malnutrition affects all age groups but young children, lactating and pregnant women are most vulnerable groups  CLASSIFICATION OF MALNUTRITION o Acute malnutrition may present itself in the form of wasting (marasmus), nutritional edema (kwashiorkor) o In acute malnutrition ---- child is wasted o Wasting is characterised by rapid loss of fat & muscle o Weight for age is low o Height for age is normal o Weight for hight is low o Chronic malnutrition develops over time and results in stunting o In chronic malnutrition --- child is stunted o Weight for age is low / normal o Height for age is low o Weight for hight is normal  OBESITY IS THE OTHER EXTREME END OF MALNUTRITION  Overnutrition Obesity Atherosclerotic heart disease Hypertension Metabolic syndrome  Prevalence of obesity (according to 2010 data of M. of Health) in Turkey 30% of adults (41% in females, 20.5% in males) 8-8.5% in children-adolescents (male>female) Prevalence of overweight in child.& adolescents ≈ 16% METHODS FOR NUTRITIONAL ASSESSMENT The purpose of nutritional assessment  Identify individuals at risk of becoming malnourished  Identify individuals who are already malnourished and start nutritional support  Measure effectiveness of the nutritional program/ intervention once it has been initiated METHODS OF NUTRITIONAL ASSESSMENT These are summarized as ABCD  Anthropometric measurements  body height, weight & head circumference  midarm circumference (muscle mass)  skinfold thickness (sc fat mass)  Biochemical, laboratory methods  Clinical methods  Dietary evaluation methods  Other anthropometric measurements Midarm  Midarm circumference circumference  Skin fold thickness Triceps Subscapular Suprailiac  Growth charts are designed according to age and sex GROWTH CHART HEIGHT for 1-18 YRS 97th percentile 90th percentile 75th percentile 50th percentile 25th percentile 10th percentile 3rd percentile WEIGHT AGE  GROWTH CHART for 0-36 months 97th percentile LENGHT 50th percentile 3rd percentile WEIGHT  97th percentile measured values 50th percentile reflects current nutritional 3rd percentile status  It is possible to differentiate between acute & chronic changes by using the same chart and putting a mark at each measurement  It is possible to differentiate between acute & chronic changes by using the same chart and putting a mark at each measurement Methods of Nutritional Assessment These are summarized as ABCD  Anthropometric methods  Biochemical, laboratory methods Measurement of serum level proteins with a short half life (prealbumin, RBP, transferrin) Total lymphocyte count  Clinical methods  Clinical manifestations of PEM  Pallor, fatigue  Rickets/osteoporosis  Glossitis  Easy fractures  Angular cheliosis  Peripheral neuropathy  Skin pigmentation  Loss of balance  Thin and sparse hair  Diarrhea  Spongy, bleeding gums  Muscle cramps  Edema  Abdominal distention  Easy bruisability  Hepatomegaly  Enlarged epiphysis of  Ascites long bones Methods of Nutritional Assessment These are summarized as ABCD  Anthropometric methods  Biochemical, laboratory methods Measurement of serum level proteins with a short half life (prealbumin, RBP, transferrin) Total lymphocyte count  Clinical methods Peripheral findings indicating deficiency of vitamins and trace elements (pallor, glossitis, rickets, etc)  Dietary evaluation methods Calculation of daily caloric intake CLASSIFICATION OF MALNUTRITION GOMEZ classification: o Parameter: weight for age o Reference standard (50th percentile) WHO charts o W/A= W(actual) / W(50th percentile) x 100 >90-110% = Normal 75-90% = 1st degree, Mild 60-74% = 2nd degree, Moderate 90-110% = Normal 75-89% = Mild 60-74% = Moderate 90% = normal 80-89% = mild malnutrition 70-79% = moderate malnutrition < 70% = severe malnutrition  GOMEZ CLASSIFICATION (wt for age) - %90-110 normal - %75-89 mild - %60-74 moderate - %90 normal - %80-90 mild - %70-80 moderate -