LEC 9 Biochemical Assessment PDF

FACTORS AFFECTING NUTRITIONAL STATUS OUTLINE # Table 1. Types of factors affecting nutritional status. BIOCHEMICAL ASSESSMENT I. REVIEW 1...

FACTORS AFFECTING NUTRITIONAL STATUS OUTLINE # Table 1. Types of factors affecting nutritional status. BIOCHEMICAL ASSESSMENT I. REVIEW 1 Physiological factors Pathological factors A.Nutrition Age Genetics 1. Malnutrition Sex Infection 2. Factors Affecting Nutritional Status Growth Medical and surgical 3. Assessment of Nutritional Status Pregnancy illnesses II. BIOCHEMICAL ASSESSMENT 1 Lactation Malignancies A.Nutrition Care Process Medications B.Routine Clinical Tests III. REVIEW QUESTIONS 4 IV. APPENDICES 5 In general, physiological factors are directly proportional to nutritional requirements (except for sex, because no sex is better than the other!) ○ Cannot be applied to sex because it is an example of a SOURCES nominal variable, meaning it describes a name, label or Chua, C.C. (2023). Biochemical assessment of nutrition. category without natural order. [Lecture Slides]. If there is inflammation, there is increased nutritional need because the body needs more energy for the immune system REVIEW to repair damaged tissues However, there is low food intake because of a lack of appetite, nausea, and vomiting (could also be from NUTRITION side-effects of certain medications) Refers to the need for the six essential nutrients NPO (no pagkain, okay?) ○ Carbohydrates ○ Nothing by mouth (nil per os), or to withhold food & fluids ○ Proteins as certain medical procedures require a fasted state ○ Lipids ○ Minerals ASSESSMENT OF NUTRITIONAL STATUS ○ Vitamins Methods of nutritional status assessment ○ Water ○ Anthropometric Nutritional requirements depend on factors such as: ○ Biochemical ○ Age ○ Clinical ○ Sex ○ Dietary ○ Activity ○ Food security* Nutritional status affects the clinical outcomes No single best test to evaluate nutritional status Imbalance in nutritional intake leads to malnutrition ○ Not enough to just base on one method and conclude ○ In the past, malnutrition has been defined as the lack of that one is nutritionally healthy energy intake or the deficiency of nutrients Information should be collected systematically ○ Anthropometric and Dietary assessments are MALNUTRITION conducted by Registered Nutritionist–Dietitians Lack of energy intake or deficiencies of nutrients. This ○ Biochemical assessments are done by medical insufficiency in nutrients is classified into two broad technologists, under the supervision of a pathologist categories: ○ Clinical exams are conducted by physicians ○ Marasmus Evaluation should be done on the overall data collected Energy or calorie deficiency ○ Kwashiorkor Protein deficiency characterized by peripheral NOTE edema As per WHO guidelines, it includes conditions caused by both The following information on “Biochemical Assessment”, up insufficient as well as excess intake of macronutrients and until before “Routine Clinical Tests”, was retrieved from Batch micronutrients: 2024 Trans unless otherwise stated through in-text citations. ○ Undernutrition Low weight-for-height BIOCHEMICAL ASSESSMENT Low height-for-age Low weight-for-age Also known as Laboratory Assessment ○ Micronutrient deficiency or excess in vitamins and Involves the same laboratory testing done for the diagnosis of minerals diseases. The only difference is how the information is going ○ Overnutrition to be used, which in this case, is in the context of nutrition Overweight (Chua, 2023). Obesity ○ Same tests and results but the analysis and Other diet-related health conditions such as type 2 interpretation of the result are within the context of diabetes mellitus (due to having constantly high nutrition blood sugar, under constant hyperglycemic state), Includes measuring a nutrient or its metabolite in: cardiovascular disorders, etc. ○ Blood (e.g., extraction of venous blood via venipuncture) ○ Feces ○ Urine PH161: BIOCHEMISTRY | GROUP A: MILLAN, RICAFORT, SIAT 1  ○ Measuring a variety of other components in blood and NUTRITION CARE PROCESS (NCP) other tissues (e.g., biopsy) that has a relationship to Nutrition Care Process (NCP) is a 4-step process (ADIME) nutritional status Makes sure that the specimens collected are indicative and a NUTRITION ASSESSMENT AND REASSESSMENT (A) reflection of a person’s nutritional status Involves the following: Process is stringently controlled and regulated as opposed to ○ Obtain/collect timely and appropriate data. Data may the other three methods (ACD) come in the form of ABCD: ○ Involves comparing control samples (standard) with Anthropometric data predetermined substance or chemical constituent Biochemical data (analyte) concentrations with every patient specimen Clinical data ○ Analyte concentrations are already deemed acceptable Dietary data to allow measurement of a particular metabolite in the ○ Analyze/interpret with evidence-based standards specimen ○ Document Laboratory data are the only real “objective data” used in nutrition assessment NUTRITION DIAGNOSIS (D) ○ ACD methods Still have some elements that are biased (i.e., highly Methods for nutrition assessment (ABCD) would be the basis influenced by the one doing the measurements or for nutrition diagnosis interpretations) Involves the following: ○ Biochemical method ○ Identify and label problem Have a standard sample to which the analytes can ○ Determine cause/contributing risk factors be compared to ○ Cluster signs and symptoms/defining characteristics As long as the analyte or specimens are not ○ Document contaminated, then results are highly accurate and reproducible NUTRITION INTERVENTION (I) Ordered to: Each diagnosis will have a particular intervention ○ Diagnose diseases (for doctors) Involves the following: ○ Support nutrition diagnoses ○ Plan nutrition intervention We have a clinical impression in mind already but Formulate goals and determine a plan of action confirmation is necessary to determine if the ○ Implement nutrition intervention impression is supported by biochemical findings Care is delivered and actions are carried out Increases the consideration of the particular disease ○ Document in mind ○ Monitor effectiveness of nutrition interventions NUTRITION MONITORING AND EVALUATION (ME) Example: Diabetic patients Each intervention for the diagnosis should have a particular Monitor the blood sugar level (FBS) or monitoring and evaluation parameter glycosylated hemoglobin (HbA1C) to determine Involves the following: the effectiveness of the oral hypoglycemic ○ Monitor progress agents that were prescribed ○ Measure outcome indicators ○ Evaluate the effectiveness of medication/s ○ Evaluate outcomes Example: Hypertensive patients ○ Document Monitor Na+ and K+ metabolites since these could be either elevated or decreased, ROUTINE CLINICAL TESTS depending on the type of antihypertensive medications being taken ○ Evaluate Nutrition Care Process (NCP) interventions 1. Serum electrolytes and hydration status may be deranged or medical nutrition therapy in malnourished individuals. Primary focus in nutrition: whether the intervention From lecture: instituted is working for the patient Analyzing the biochemical components of blood If not, either: Recall: Blood is composed of plasma and cells. Dissolved Improve the intervention elements in blood are called humoral components. Totally change the intervention Electrolytes mainly come from diet (e.g. sodium, potassium, Best to compare current results to historic baseline test result, calcium, and chloride). These are essential for muscle if available, to see trends contraction, acid-base balance, and act as coenzymes. ○ If the patient already possesses several results of a Electrolytes are affected by hydration; dehydration and particular nutrition parameter, it would be best to look at overhydration are both fatal. (Both are nakakamatay, parang the past results for baseline comparison pagmamahal, pag nasobrahan, masasakal ka) ○ Determines whether the present result is: Dehydration: Water is plasma and plasma is blood. If there is Primary elevated not enough plasma → not enough blood → not enough The same as before oxygen to organs → hypovolemic shock Decreased ○ Insufficient perfusion of blood in the body ○ Trends can only be seen if there are more data available ○ Hypovolemic shock is an emergency condition in which Results are interpreted in the context of severe blood or other fluid loss makes the heart unable to genetic/environmental factors pump enough blood to the body. This type of shock can ○ Often forgotten cause many organs to stop working. ○ Each individual is affected by particular Overhydration (only happens in deliberate/severe cases): genetic/environmental factor/s ○ This will dilute the electrolytes and can affect the Example: diet alone could impact one’s disposition contractual system of the heart, which leads to towards a particular disease hypokalemia Part of the Nutrition Care Process (NCP) ○ Note: blood vessels will not burst because there are kidneys! Wow J.P.M., I.D.R, & A.T.S._UPM CPH 2 2. Blood urea nitrogen (BUN) and serum creatinine Predictors of nitrogen balance along with being indicators of 5. Low cholesterol levels can be seen in undernourished renal function, and lower levels of these can be seen in individuals. malnourished patients. Low levels of serum creatinine can be indicative of lower 6. Low hemoglobin is suggestive of anemia. muscle mass. Both BUN and creatinine levels, however, can be affected by From lecture: hydration levels and kidney function. Hemoglobin can be obtained through Complete Blood From lecture: Count (CBC). It is called BUN because in the laboratory, we do not (and Iron deficiency can lead to anemia (can be measured) cannot) measure the urea. Rather, nitrogen is measured and used to infer how much urea was naturally present. 7. Undernutrition and protein deficiency, in general, lead to Urea comes from protein metabolism (mostly) and nucleic impaired immune response. acid metabolism (only in small amounts). ○ If the body breaks down protein for whatever use, it becomes urea. 8. Lymphocyte functioning and proliferation are affected in ○ Nucleic acid metabolism major byproduct: uric acid chronic malnutrition and may manifest as decreased (which has a similar chemical structure with urea) lymphocyte count. Creatinine is a byproduct of muscle catabolism. Urea and creatinine are nitrogenous compounds harmful to 9. Levels of visceral proteins such as albumin, prealbumin, organs. In fact, increased nitrogen concentration in the blood transferrin, and retinol-binding protein can help evaluate is called azotemia. nutritional status. ○ Both substances are dangerous for all organs but are particularly harmful to the brain and liver. From lecture: Since these are toxic compounds, the body needs to release Albumin these compounds. This can be done through the kidney. ○ Main protein in the blood, maintains colloidal osmotic ○ Urea and creatinine are excreted in the kidneys through pressure in the blood the urine. Under normal circumstances, water is located ○ Thus, between urine and serum, urine has a higher intravascularly. Water is kept inside the blood vessels by the concentration of urea and creatinine. albumin. ○ However, in the event of kidney impairment (i.e. end Question: What happens when the osmotic pressure in the stage renal disease, acute renal failure), urea and blood vessel is not maintained? creatinine are retained in the blood. Answer: When albumin levels decrease, the concentration ○ Thus, in routine clinical diagnosis, high BUN and outside the blood vessels becomes higher than inside, creatinine indicate kidney failure or muscle wasting leading for water to follow the area of higher concentration. diseases. Plasma moves from blood vessels to the tissues. This Despite being routinely used for assessing kidney diseases, results in edema (manas). these two parameters can also be used to assess nutritional Thus, in hypoproteinemia or protein losing nephropathy status (i.e. higher concentration of creatinine can indicate (kidneys pumping out protein), edema is evident. In order to muscle wasting disease) counter edema, albumin levels must be restored. Same effects with electrolytes in the context of hydration. For nutritional assessment (i.e. nutritional intake of protein), ○ Dehydrated: BUN and creatinine are falsely high. albumin cannot be used as a parameter due to its long half life. Prealbumin, transferrin, and retinol-binding proteins are used over albumin because they have shorter half-lives 3. Elevated blood glucose levels and lipid profile (triglycerides (~2-3 days of half-life) and cholesterol) levels – indicative of a metabolic ○ Long half-life: even if a person does not consume syndrome albumin in the past three days, albumin is still present in From lecture: the body because its half-life is 20 days. But other than metabolic diseases, elevated levels can be due to excess intake. 10. Low serum albumin levels suggest protein deficiency due However, there are also situations that despite normal or less to malnutrition and other pathologies that affect the protein than normal intake, glucose and lipid levels are high status, such as liver cirrhosis or nephrotic syndrome. ○ i.e. Type 1 diabetes: metabolic disorder; familial hypercholesterolemia: cells lack the receptors for LDL From lecture: resulting to lipids not going to the cells and remaining in Low albumin levels can result from liver disease (liver the blood synthesizes all protein including albumin except for End point: use these two parameters to check for metabolic antibodies) and kidney disease disorders, but do not discount the reason for elevated levels ○ Kidney reabsorbs protein. So, in the case of a kidney being excess intake. disease, protein leaks into the urine which can be a cause of missing/lack of protein (hence the name protein losing nephropathy) 4. Hyperglycemia can also be a nonspecific indicator of the ○ Either the body stops making protein (liver damage) or inflammatory response. loses protein (kidney damage) From lecture: Question: How is there hyperglycemia when there is 11. High levels of serum albumin could be associated with decreased intake of sugar and excess consumption of sugar dehydration. by white blood cells during an inflammatory response. Answer: There is hyperglycemia because the body is trying Same explanation as with electrolytes to feed white blood cells and damaged tissues. This comes from the body’s storage (body’s feedback mechanism) 12. Micronutrient levels ○ Glycogenolysis ○ Gluconeogenesis (when glycogen runs out) B vitamins (thiamine, riboflavin, niacin, pyridoxine, folic acid, ○ Both results to hyperglycemia B12), vitamins A, C, D, E, and K, iron, zinc, selenium, ○ That is why when you want to lose weight, try getting sick homocysteine, etc., can be measured. (joke) From lecture: ○ Usually used for enzyme activity. J.P.M., I.D.R, & A.T.S._UPM CPH 3  ○ If there is enzymatic disorder, it can be due to either of the two: Genetic REVIEW QUESTIONS Low intake (can be cured through vitamin/mineral supplementation) 1. TRUE or FALSE: Sex is directly proportional to an individual’s More specific tests such as the Schilling test for B12 nutritional requirements deficiency or the iron panel to differentiate between 2. TRUE or FALSE: Malnutrition is characterized as both different types of anemia (types: size, appearance of RBCs) insufficient and excess intake of micronutrients and From lecture: macronutrients. ○ Iron deficiency anemia: microcytic, hypochromic 3. Which of the following is NOT indicative of undernutrition? anemia a. Low weight-for-height ○ Diphyllobothrium Vitamin B12 deficiency (e.g. b. Low height-for-age Diphyllobothrium latum infections: megaloblastic c. Low head circumference-for-age anemia (large RBCs) d. Low weight-for-age 4. Who is typically responsible for conducting anthropometric 13. Acute phase reactants (i.e. transferrin, CRP) and dietary assessments to evaluate nutritional status? a. Registered Nutritionist–Dietitians C-reactive protein (CRP) - indicate inflammation b. Physicians From lecture: c. Medical technologists Inflammation: higher nutrient requirement d. Pathologists Examples: CRP, transferrin 5. What is the potential consequence of overhydration related to ○ Most common type of acute phase reactant electrolyte imbalance in the body? a. Hypovolemic shock NOTE b. Increased muscle contraction c. Hypokalemia See Appendix A for table of metabolic tests d. Bursting of blood vessels due to excess fluid No need to memorize reference ranges 6. Which of the following is NOT a pathological factor affecting What to take note of: What happens during high/low nutritional status? levels of [parameter] a. Medical and surgical illnesses b. Pregnancy c. Malignancies d. Medications 7. When a person suffers from dehydration, his blood urea nitrogen and serum creatinine will come out as: a. True positive b. Falsely positive c. True negative d. Falsely negative 8. Two of the body’s feedback mechanisms during an inflammatory response resulting in hyperglycemia. a. Glycogenesis and glycogenolysis b. Glycogenesis and gluconeogenesis c. Gluconeogenesis and lipolysis d. Glycogenolysis and gluconeogenesis. 9. TRUE OR FALSE. Albumin cannot be used to measure nutritional intake status because of its short half-life. 10. This test can be used to differentiate different types of anemia. a. Complete blood count b. Schilling test c. Iron panel d. Serum electrolyte test ANSWER KEY 1) FALSE 3) C Concept of proportionality 4) A cannot be applied to sex, a 5) C nominal variable, as we cannot 6) B say male is greater than 7) B female or vice versa when 8) D talking about increased needs 9) FALSE of nutritional requirements Long half-life 2) TRUE 10) C J.P.M., I.D.R, & A.T.S._UPM CPH 4  APPENDICES Appendix A. Metabolic tests used in Biochemical Assessment. Metabolic Tests Test Normal Test Low number High Number Glucose 70-99 milligrams hypoglycemia, liver disease, hyperglycemia, certain types of (mg)/deciliter (dL) adrenal insufficiency, excess insulin diabetes, prediabetes, pancreatitis, hyperthyroidism Blood Urea Nitrogen (BUN) 7-20 mg/dL malnutrition liver or kidney disease, heart failure Creatinine 0.8-1.4 mg/dL low muscle mass, malnutrition chronic or temporary decrease in kidney function BUN/Creatinine ration 10:1 to 20:1 malnutrition blood in bowels, kidney obstruction, dehydration Calcium 8.5-10.9 mg/dL calcium, magnesium, or vitamin D excess vitamin D intake, kidney deficiency, malnutrition, disease, cancer, hyperthyroidism pancreatitis, neurological disorders Protein 6.3-7.9 grams (g)/dL liver or kidney disease dehydration, liver or kidney disease, multiple myeloma Albumin 3.9-5.0 g/dL liver or kidney disease dehydration Alkaline Phosphatase (ALP) 44-147 international malnutrition Paget’s disease or certain disease that units (IU)/liter (L) spread to bones, bile duct obstruction, liver cancer Alanine amino-transferase 8-37 IU/L generally not a concern certain toxins such as excess (ALT) acetaminophen or alcohol, hepatitis Red blood cell count Male: 4.7-6.1 Mill/mcL iron, vitamin B12, or folate dehydration, renal problems, Female: 4.2-5.4 deficiency, bone marrow damage pulmonary or congenital heart disease Mill/mcL Hemoglobin (Hb) Male: 13.8-17.2 g/dL iron, vitamin B12, or folate dehydration, renal problems, Female: 12.1-15.1 g/dL deficiency, bone marrow damage pulmonary or congenital heart disease Hematocrit Male: 40.7%-50.3% iron, vitamin B12, or folate dehydration, renal problems, Female: 36.1%-44.3% deficiency, bone marrow damage pulmonary or congenital heart disease Mean corpuscular volume 80-95 femtoliters iron deficiency Vitamin B12 or folate deficiency (MCV) Mean corpuscular 27-31 picograms iron deficiency Vitamin B12 or folate deficiency hemoglobin (MCH) Platelet count 150-400 thousand/mcL viral infections, lupus, pernicious Leukemia, inflammatory conditions anemia (due to vitamin B12 deficiency) White blood cell count 4,500-10,000 autoimmune illness, bone marrow Infection, inflammation, cancer, stress, cells/microliter (mcL) failure, viral infections intense exercise J.P.M., I.D.R, & A.T.S._UPM CPH 5